Whisperwood Nursing & Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 114 beds and averages 76.0 residents a day — about 67% occupied, or roughly 38 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.448 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.16 hrs/resident/day on weekends vs 3.48 on weekdays — 9% thinner on weekends. RN hours go from 0.36 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 96% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

32 citations, most serious first. The 16 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · J2025-08-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the residents had the right to be free from verbal abuse and neglect for 2 (Resident #1 and #2) of 7 residents reviewed for abuse. The facility staff failed to protect Resident #1 from verbal abuse from Resident #2 on 7/11/25 between 7:00 PM and 7:30 PM.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/25/25. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of abuse, neglect, trauma, injury and psychosocial harm. Findings included: Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-08-15 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 7 residents (Resident #1, and #2) reviewed for abuse. CNA A failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to the facility's Abuse Coordinator involving Resident #1and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.LVN B failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to the facility's Abuse Coordinator involving Resident #1and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The ADM failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to HHSC involving Resident #1 and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The facility failed to notify Resident #1's family of the verbal abuse incident that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The facility failed to put protective…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-08-15 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 2 of 7 residents (Resident #1, and #2) reviewed for abuse. CNA A failed to report the allegation of abuse involving Resident #1 and Resident #2, to the abuse Coordinator (ADM) on 7/11/25 when she heard Resident #2 verbally assault Resident #1 between 7:00 PM and 7:30 PM.LVN B failed to report the allegation of abuse involving Resident #1 and Resident #2, to the abuse Coordinator (ADM) on 7/11/25 when she heard Resident #2 verbally assault Resident #1 between 7:00 PM and 7:30 PM.The Abuse Coordinator (ADM) failed to follow the facility's abuse policy by not reporting to HHSC…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-08-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment for 2 of 7 residents (Resident #1, #2) reviewed for abuse.The facility failed to immediately implement protective measures to protect Resident #1 from Resident #2 after a verbal abuse incident occurred on 7/11/25 between 7:00 PM and 7:30 PM.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/14/25. The facility had corrected the noncompliance before the survey began.These failures could place residents as risk for further abuse to include emotional and physical.Findings Included: Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system).…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-07-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that 1 of 8 residents (Resident #1) reviewed for quality of care was offered a therapeutic diet when there is a nutritional problem, and the health care provider ordered a therapeutic diet.On 6/27/25 the facility did not ensure Resident #1 received her physician ordered NPO diet Enteral Feed diet (a method of providing nutrition directly into the gastrointestinal tract) when CNA provided Resident #1 with a plate of puree food (chili dog on a bun, sauerkraut, tater tots, diced onions, assorted gelatin; pureed). An IJ was identified on 07/02/25 at 2:50 PM. The IJ template was provided to the facility on [DATE] at 2:50 PM. While the IJ was removed on 7/03/25 at 9:23 AM, the facility remained out of compliance at a scope of no harm and a severity level of isolated because all staff had not been trained on 7/03/25.This failure put residents at risk for health complications related to nonadherence to diet order. Findings…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #4) reviewed for elopement. The facility failed to supervise Resident #4 while he was outside smoking. When the gate opened on 12/05/2024, Resident #4 was able to exit through the gate and leave the grounds. An Immediate Jeopardy situation was determined to have existed on 12/05/2024. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 12/05/2024 before the beginning of the survey. This failure could place residents at risk for serious injury, harm, impairment, or death. Findings included: Record Review of Resident #4's facesheet dated 12/10/2024 revealed that Resident #4 was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #4 had a medical history of neuroleptic induced parkinsonism (condition that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2026-04-22 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Resident #1, specific to Resident #1's dietary needs ordered by the physician. This failure could place residents at risk of not receiving the care required to meet their individualized needs.Findings include: Record review of Resident #1's face sheet, dated 04/21/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Dementia in other diseases classified elsewhere, moderate without agitation (a decline in cognitive abilities that affects a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident was offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for 1 of 5 residents (Resident #1) reviewed for therapeutic diets.The facility failed to ensure Resident #1 was given supplemental shakes at every meal (three times a day) as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.Findings include: Record review of Resident #1's face sheet, dated 04/21/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: Dementia in other diseases classified elsewhere, moderate without agitation (c a decline in cognitive abilities that affects a person's daily functioning), age related cognitive decline, dysphagia (difficulty swallowing), Parkinson's disease with dyskinesia and fluctuations…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-23 · tag F0812 — failed to store, cook, and serve food safely — isolated
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure the dishwasher was working properly with the hot water temperature and the facility failed to allow the food processor for puree to air-dry completely before using. These failures could place residents at risk for food contamination and foodborne illness. The findings include: Observations during the puree process on 01/21/26 at 11:36 AM revealed [NAME] A pureed hamburger patties in the food processor. After the hamburger patties were pureed, [NAME] A transferred the food to a smaller container and then [NAME] A washed the food processor in a 3-compartment sink and then placed the food processor on a tray to go through a wash cycle in the low temperature/chemical dishwasher. The food processor was removed from the tray when the wash cycle was completed, and the food processor was then picked up and placed back on the machine…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-23 · tag F0813 — isolated
  Have a policy regarding use and storage of foods brought to residents by family and other visitors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 Resident's personal refrigerators reviewed for food safety (Resident #66) in that: The facility did not have a system in place to assist residents in cleaning and maintaining their personal refrigerators to ensure safe food handling and prevent consumption of spoiled and/or expired foods. The personal refrigerator in Resident #66's room did not contain a thermometer. The refrigerator contained an unknown substance that was unlabeled and undated. Resident #66 was unable to identify an unlabeled and undated unknown substance in the personal refrigerator. These failures could place residents at risk for food borne illnesses.Findings include: Record review of Resident #66's electronic face sheet dated 01/23/2026 revealed a [AGE] year-old female admitted to the facility on [DATE]. The face sheet included the following diagnoses: Schizoaffective disorder,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-23 · tag F0849 — isolated
  Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 Residents (Resident #6) reviewed for hospice care: The facility failed to ensure Resident #6 had a physician's order for hospice care. This failure could result in residents not receiving care without a physician's order.The findings included: Record review of the admission record for Resident #6, dated 01/21/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: dementia (a decline in mental ability), dysphagia (difficulty swallowing), and age-related cognitive decline. The admission record revealed Resident #6 used Hospice Company A. Record review of the annual MDS for Resident #6, dated 10/07/25, Section O revealed Resident #6 was receiving hospice services. Record review of the care plan for Resident #6, last reviewed on 12/10/25, revealed a focus area for:…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-15 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately notify with the responsible party of an incident involving the resident which had the potential for requiring physician intervention for 2 (Resident #1 & Resident #2) of 7 residents reviewed for notification of change.The facility failed to immediately notify Resident #1's responsible party when Resident #2 verbally abused Resident #1 on 7/11/25 between 7:00 PM and 7:30 PM. This failure could place residents responsible party at the risk of not being aware/informed of residents' conditions. Findings included:Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-19 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 10 residents (Resident #1, and #2) reviewed for abuse. The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not notifying the family representative regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not conducting a thorough investigation and documenting regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-19 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the administrator of the facility for 2 of 10 residents (Resident #1 and #2) reviewed for reporting abuse, in that: The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. These failures could place residents as risk for abuse and neglect. Findings included: Record review of Resident #1's face sheet, dated 03/19/25, revealed an [AGE] year-old-male was admitted to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated for 2 of 10 residents (Resident #1, and #2) reviewed for abuse. The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not conducting a thorough investigation and documenting regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. Findings included: Record review of Resident #1's face sheet, dated 03/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), major depressive disorder, and anxiety. Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-07 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality and the facility failed to protect and promote the rights of the resident for 4 of 21 residents (Resident #9, Resident #26, Resident #41, and Resident #231) reviewed for resident rights in that: 1. CNA H failed to knock on the door prior to entering Resident #41's room during wound care. 2. CNA I failed to provide full privacy while providing peri care for Resident #9 3. CNA E and CNA F failed to provide full privacy while providing peri care for Resident #231. 4. Resident #26 was observed with no clothes on, just a brief and right sock on while in his room with the door open on 11/05/2024 and 11/06/2024. These failures could place residents at risk for diminished quality of life and loss of dignity and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$19,546 in federal fines across 2 penalties.

• $10,546 — penalty dated 2025-08-15
• $9,000 — penalty dated 2024-12-12

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CREATIVE SOLUTIONS IN HEALTHCARE — 149 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 16 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX