Village Creek Rehabilitation and Nursing 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.

49.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 44.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 120 beds and averages 75.5 residents a day — about 63% occupied, or roughly 44 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 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.77 hrs/resident/day on weekends vs 3.47 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.20 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

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 more than at the previous inspection — worsening. 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.

38 citations, most serious first. The 16 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · Kcited before2026-03-26 · tag F0607 — failed to have anti-abuse policies — pattern
  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 observation, interview and record review, the facility failed to implement written policies and procedures that identify, report, and protect from further abuse of residents, for 2 of 6 residents (Resident #14 and Resident #55) reviewed for abuse. * On 03/04/26, CNA B witnessed Resident #14 yell at Resident #55 that she was a [f-ing retard]. The incident was not reported to the abuse coordinator (AC) or HHSC. No preventative measures were put in place to prevent further abuse. * On 03/20/26, CNA B and MA C both witnessed Resident #14 shove Resident #55 into trash and dirty linen barrels in her wheelchair. CNA B and MA C did not consider this to be abuse and did not report the incident to the abuse coordinator. An Immediate Jeopardy (IJ) situation was identified on 03/25/26. While the IJ was removed on 03/26/26, the facility remained out of compliance at a severity of more than minimal harm that was not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness…

  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
• Immediate jeopardy · J2026-03-26 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 assure all nursing staff possess the competencies, and skill sets necessary to use, maintain and test the automated external defibrillator according to the manufacturer's guidelines for 1 of 1 facility automated external defibrillators and 4 of 4 licensed staff interviewed (LVN QQ, LVN L, LVN J and LVN H) and reviewed for nursing services.The facility failed to ensure nursing staff were competent to conduct testing of the facility's only AED according to the manufacture's guidelines.An Immediate Jeopardy (IJ) was identified on [DATE] at 4:45 p.m. While the IJ was removed on [DATE] at 5:45 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.This failure could place residents at risk for death.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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-11-21 · 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 residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents.The facility failed to provide adequate supervision with Resident #1 on 08/11/2025 while completing perineal care in bed. CNA A provided perineal care and Resident #1 rolled off the bed to the floor. Resident #1 initially complained of pain in his right arm after this fall. Resident #1 was sent to the hospital for further evaluation on 08/11/2025.The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 8/11/2025 and was removed on 08/11/2025. The facility corrected the noncompliance before the investigation began.These failures placed residents at risk for hospitalization, harm and serious injury. Findings included: Record review of Residents #1's face sheet reflected a [AGE] year-old male with an admission date of 5/05/2025. Resident #1's diagnoses included…

  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
• Immediate jeopardy · Jcited before2024-11-21 · 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 interviews and record review, the facility failed to ensure residents the right to be free from abuse for 1 of 16 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from sexual abuse on 08/28/24 and 09/02/24. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on monitoring behaviors after an inappropriate behavior was identified. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet dated 11/19/24 indicated he was a [AGE] year-old male admitted on [DATE]. His diagnoses included unspecified intracranial injury without loss of consciousness (brain injury), major depressive disorder (mental disorder), and other sequelae of non-traumatic…

  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
• Immediate jeopardy · Jcited before2024-11-21 · 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 interviews and record review, the facility failed to develop and implement the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 2 of 16 residents (Resident #1 and Resident 3) reviewed for care plans. 1. The facility failed to develop and implement interventions in the care plan to prevent Resident #1's sexual abuse of Resident #2. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because resident care plans were not reviewed and revised. 2. The facility failed to develop and implement Resident #3's care plan and interventions to prevent Resident #3's verbal and emotional abuse of Resident #4. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet…

  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
• Actual harm · G2026-03-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 provide the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 2 residents (Resident #5) reviewed for indwelling catheters/ quality of care. (Resident #5) 1. Resident #5 had blood present inside his suprapubic catheter (a tube inserted into the bladder to drain urine) tubing and catheter drainage bag from 03/21/2026- 03/24/2026. 2.The facility staff failed to assess, document, and report findings to the physician and Resident #5 continued with signs of a possible UTI. 3.Resident #5 did not have a suprapubic strap in place to prevent dislodgement or trauma. This failure could place residents at risk of not receiving the required level of care, trauma, or possible sepsis. Findings included: Record review of a face sheet dated 03/25/2026 indicated Resident #5 was a [AGE] year-old male admitted on initially admitted on [DATE] and readmitted [DATE]. His diagnoses included chronic respiratory…

  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 · E2026-03-26 · tag F0580 — failed to tell family and doctor about changes — pattern
  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 ensure the physician was consulted regarding a need to alter treatment for 1 of 16 residents reviewed for notification of changes. (Resident #41). The facility failed to notify Resident #41's physician regarding the pattern of low blood pressure and of her low blood pressure medication being held for 14 out of 23 days for the month of March 2026. This failure could place residents at risk for complications due to delayed or failed physician intervention.Findings included:Record review of Resident #41's face sheet dated 03/25/2026 indicated she was a [AGE] year-old female admitted [DATE] with diagnoses of Alzheimer's disease with late onset (progressive disease that destroys memory and other important [NAME] l functions), dementia (loss of cognitive functioning), and hypertension (high blood pressure).Record review of Resident #41's quarterly MDS assessment dated [DATE] indicated a diagnosis of high blood pressure and a BIMS of 6. A BIMS score of 6…

  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 · E2026-03-26 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  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, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 2 of 6 residents (Residents #9 and #10) reviewed for services provided to meet professional standards. 1. LVN A administered gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications) medications to Resident #9 without flushing the tube with water before and after medication administration or between medications on 03/24/26 during medication pass.2. LVN G mixed GlycoLax (laxative) in water then mixed crushed gastrostomy tube medications for Resident #10 with the mixture on 03/25/26 during the medication pass.3. LVN G flushed the gastrostomy tube with the GlycoLax mixture instead of water before medication administration and between medications on 03/25/26 during the medication pass. These failures could place residents at risk of inaccurate drug…

  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 · E2026-03-26 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  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 ensure a medication error rate of less than 5 percent. There were 5 errors out of 31 opportunities, resulting in a 16.13% percent medication error involving 3 of 6 residents reviewed for medication pass. (Residents #6, #9, and #10) * LVN A administered gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications) medications to Resident #9 without flushing the tube with water before and after medication administration or between medications on 03/24/26 during medication pass. * LVN A administered Metoclopramide (gastrointestinal stimulant/anti nausea) to Resident #9 on continuous enteral feeding during the medication pass. * MA C administered docusate sodium (stool softener) 100mg 1 capsule to Resident #6 when the physician order was for 2 capsule during the medication pass. * LVN G mixed GlycoLax (laxative) in water then mixed crushed gastrostomy tube medications for Resident #10 with the mixture during the medication pass. * LVN G flushed 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-26 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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 ensure that residents were free of significant medication errors, for 3 of 8 residents (Residents #5, #4, and #10), reviewed for significant medication errors. * The facility did not ensure Residents #5, #4, and #10 did not receive Midodrine (medication used to raise the blood pressure) when there were parameters to hold the medication. This failure could place residents receiving medication to elevate the blood pressure at risk for stroke, hospitalization, and decreased quality of life.Findings included: 1. Record review of a face sheet dated 03/25/2026 indicated Resident #5 was a [AGE] year-old male admitted on initially admitted on [DATE] and readmitted [DATE]. His diagnoses included chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot supply enough oxygen to the blood, often due to underlying lung or systemic diseases), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-26 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  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 ensure the planned menus were followed and prepared according to the weekly menu for 1 of 4 meals reviewed for food and nutrition services. (Lunch meal) The facility failed to ensure the menu was followed for the lunch meal on 03/23/2026. This failure placed the residents at risk of not receiving meals that are adequate to meet their nutritional needs and a decline in nutritional health status.The findings included:Review of the facility's weekly menu, for Week 4, dated 03/12/2026 indicated the following menu plan:03/23/2026 Monday Lunch: Smothered Chopped steak, black-eyed peas, spinach, garlic cheese biscuit, sherbert, tableside condiments, water and choice of beverage. Review of the Menu board posted outside of the dining room on 03/23/2026 at 11:28 a.m. indicated the following: lunch menu for the day: spaghetti, tossed salad, vegetable blend, garlic cheese biscuit, and sherbert. No substitute or Everyday Menu posted in the dining room. There was no weekly menu posted in the dining room.During a dining…

  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 · D2026-03-26 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  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 an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 18 residents (Residents #56) records reviewed for resident assessments. The facility failed to ensure the discharge MDS assessment was completed and transmitted as required for Resident #56. This failure could place residents at risk of not receiving care and services as needed.Findings included: Record review of admission record for Resident #56, dated 03/26/2026, indicated Resident #56 was admitted on [DATE], was an [AGE] year-old female with diagnoses of ventricular premature depolarization (an early heartbeat originating from the heart's ventricles, causing a temporary disruption in the normal heart rhythm), dementia (loss of cognitive functioning), diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar), anxiety (persistent and excessive worry that interferes with daily activities),…

  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 · D2026-03-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  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 each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use) for 1 of 5 residents (Residents #9) reviewed for unnecessary medications. The facility failed to hold Resident #9's Carvedilol (used to lower blood pressure) medication (for 2 administration) when the blood pressure was outside the prescribed parameters. These failures could place residents at risk for at risk for adverse reactions and decline in health condition .Findings included:Record review of Resident #9's face sheet indicated a [AGE] year-old female admitted on [DATE] with diagnosis of stroke affecting her left non-dominant side with paralysis, high blood pressure, and difficulty swallowing with a feeding tube. Record review of Resident #9's quarterly MDS assessment, dated 02/15/2026, indicated a BIMS score of 10 indicating Resident #9 was moderately impaired cognitively. Hypertension was included as one of…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-26 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #9) observed for dressing changes. * LVN A did not change gloves, sanitize/wash hands between glove changes, and touched clean items with dirty gloves when providing dressing change to Resident #9. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a face sheet dated 03/24/26 indicated Resident #9 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications). Record review of the quarterly MDS dated [DATE] indicated Resident #9 was rarely understood by others and sometimes…

  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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-26 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working safely.
  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 maintain and test the automated external defibrillator according to the manufacturer's guidelines for 1 of 1 facility automated external defibrillators reviewed for physical environment. 1. The facility did not maintain a working automated external defibrillator (AED - used during sudden cardiac arrest) for use in the administration of CPR. On [DATE], the AED was beeping, electrodes were not attached, and the machine had a red x indicating the AED was not in safe operating condition.2. The facility had not tested the AED according to the manufacture's guidelines from [DATE] to [DATE] (total of 23 days).These failures could place residents who had a full code status at risk of not receiving necessary life-saving measures, decline in health, and death. Findings included:During an observation on [DATE] at 2:30 p.m., the only available AED for the facility was sitting in a holder that was attached to the wall outside of the nurse's station.…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-05 · 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 observation, interview, and record review, the facility failed to ensure that alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 7 residents (Resident #1) reviewed for reporting. The facility failed to ensure LVN A reported injury of unknown origin found on Resident #1 to the Administrator on 06/20/2025. This failure could place residents at risk for injuries of unknown origin not being reported.Findings included: Record review of Resident #1's face sheet, dated 10/20/2025, indicated Resident #1 was a [AGE] year-old male with an initial admission date of 03/30/2023 and re- admitted on [DATE]. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score of 03 indicating severe cognitive impairment. His diagnoses included Type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), seizure disorder (abnormal electrical activity in the brain leading to recurrent seizures.), autistic…

  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

“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

$105,486 in federal fines across 3 penalties.

• $37,798 — penalty dated 2026-03-26
• $13,250 — penalty dated 2025-11-21
• $54,438 — penalty dated 2024-11-21

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 NEXION HEALTH — 51 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

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.

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