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Mesquite Tree Nursing Center

434 Paza Dr., Mesquite, TX 75149 · Government - Hospital district · 143 certified beds · (972) 288-6489 Medicare & Medicaid certified

Call the home — (972) 288-6489 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 20241 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (59%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1200 E Davis St Ste 113 · (972) 295-9090 · Call to confirm hours
Pharmacy
1500 S Belt Line Rd · (972) 285-1352 · Call to confirm hours
Grocery
1500 S Belt Line Rd · (972) 285-0226 · Call to confirm hours
Park
Agnew Park<0.1 mi
Agnew Park, Rupard St · Typically dawn to dusk
Place of worship

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

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.3%15.8%15.4%better
Long-stay residents who lose too much weight1.4%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.6%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.5%3.3%3.3%better
Long-stay residents whose ability to walk worsened5.5%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.2%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers2.7%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control6.9%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.1%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine97.4%88.0%79.4%better
Short-stay residents rehospitalized after admission22.5%25.7%22.6%typical
Short-stay residents with an outpatient ER visit13.8%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.492.171.67better
Long-stay outpatient ER visits per 1,000 resident days1.172.061.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

11.6%U.S. median 10.7%
Went back to hospital
0.33U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 7.0–17.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified65.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.40
RN hours/ resident / day
0.70
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.23
Total nurse hours/ resident / day
0.34
RN hoursweekends
58.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 143 beds and averages 83.3 residents a day — about 58% occupied, or roughly 60 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 2.86 hrs/resident/day on weekends vs 3.38 on weekdays — 16% thinner on weekends. RN hours go from 0.42 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above 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

2
deficiencies at the latest standard inspection (2026-03-05)
5
at the previous standard inspection (2024-12-20)

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.

ABCDEFGHIJKL

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · J2023-08-27 · tag F0760 — failed to prevent significant medication errors — isolated
    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 interview and record review the facility failed to ensure resident was free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 was free of any significant medication errors by failing to ensure a resident received the correct prescribed intravenous (IV) medication, which resulted in the resident being given an IV medication that she had a known allergy to. This failure resulted in a PNC IJ (Past Non-Compliance Immediate Jeopardy), the IJ (Immediate Jeopardy) started on 08/24/2023 and ended on 08/26/2023. The facility had corrected the IJ (Immediate Jeopardy) prior to entry for abbreviated survey. There was no resident in the facility on IV therapy, facility had completed staff in-service on medication administration and LVN A had been educated on medication administration prior to entry. This failure could place residents at risk of complications from deterioration in health, potential for severe…

    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 · Past Non-Compliance
  • Potential for harm · E2026-06-24 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    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 each resident with nourishing, palatable, well-balanced diet that meets the resident's nutritional needs for 2 of 5 residents (Resident #1 and Resident #2) reviewed for dietary needs.The facility's kitchen failed to prepare and serve 3 ounces of pork loin as stated on resident meal tickets on 06/24/2026.This failure places residents at risk of not meeting their daily nutritional needs and could result in weight loss or decline in overall quality of health. Findings included:Record review of Resident #1's face sheet, dated 06/24/2026, revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnosis of cerebrovascular disease (condition that impacts blood vessels in the brain). Other pertinent diagnoses include protein-calorie malnutrition.Record review of Resident #1's quarterly MDS, dated [DATE], revealed he had a BIMs score of 14 (indicating intact cognitive function). His active diagnosis included malnutrition.Record…

    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 no plan of correction
  • Potential for harm · Ecited before2026-06-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure a bag of dry rolled oats were not sitting on the floor in the kitchen preparation area.The facility failed to ensure raw meat was being thawed properly.The facility failed to ensure food items were not in the same sink compartment as used dishes.These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included:Observation on 06/24/2026 at 12:19 PM of the facility's kitchen revealed a 50 lb bag of rolled oats sitting on the kitchen floor leaning up against a food preparation table.Observation on 06/24/2026 at 12:38 PM of the facility's 2 compartment sink, next to the handwashing sink, revealed a large piece of raw pork loin, uncovered and unsealed in a large metal pan, with a food strainer in the 1st compartment. After the surveyor noticed the meat, the DM turned on the cold water to run over the raw…

    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 no plan of correction
  • Potential for harm · D2026-05-20 · tag F0641 — isolated
    Ensure each resident receives an accurate 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 assessments accurately reflected the resident's status for 2 of 5 residents (Resident #1 and Resident #4) reviewed for resident assessments.The facility failed to accurately assess and document Resident #1's active medical diagnosis of depression.The facility failed to accurately assess Resident #4's antidepressant medication status.The facility failed to accurately document Resident #4's active medical diagnosis.These failures could place residents at risk of having inaccurate diagnoses and inappropriate identification of care needs.1. Record review of Resident #1's face sheet, dated 05/20/2026 revealed a [AGE] year-old male with a primary diagnosis of encephalopathy (abnormal brain function, lead to cognitive impairment). Other pertinent diagnoses include cerebral infarction (stroke), cognitive communication deficit (impaired ability to communicate), and mild cognitive impairment (noticeable cognitive decline). Record review of Resident #1's…

    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 · Ecited before2026-03-05 · tag F0656 — failed to write and follow a full care plan — pattern
    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 interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for three residents (Resident #1, Resident #2, and Resident #3) of 11 residents reviewed for care plans.The facility did not develop a comprehensive person-centered care plan to address the discharge plans of Resident #1, Resident #2, and Resident #3.This failure could place residents at risk of not having their discharge goals met.The findings were:Resident #11) Record review of Resident #1's Face Sheet reflected a 56 years-old male who was re-admitted to the facility on [DATE] with diagnoses including in part: sepsis (a life-threatening reaction to an infection), metabolic encephalopathy (a change in how the brain works due to an underlying condition), and multiple sclerosis (a disease where the immune system attacks the brain 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure Dietary Aide A wore a hairnet.The facility failed to ensure two 32-ounce pitchers of dark red liquid were labeled with the name of the product and dated with the use by date.The facility failed to ensure that meat that was submerged in a bowl full of water in the sink was thawed out under running water.The facility failed to ensure on 03/03/26 1 of 2 drink pitchers that held a dark yellow orange liquid were labeled with the name of the product and dated with the use by date, in 1 of 2 stand-by refrigerators.The facility failed to ensure a 3.5-gallon tea urn was labeled with the name of the product and dated with the use by date.The facility failed to ensure ground meat in a metal bin not in its original package, brown meat in a metal bin not in its original package, and vegetables with meat in a metal bin and not in its original package were labeled 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 notify the resident and the ombudsman of the transfer or discharge and the reason for the move in writing for 1 of 2 residents reviewed for discharge rights. The facility failed to ensure Resident #1 was notified in writing of the details of the transfer. The facility failed to notify the ombudsman of Resident 1's transfer. This failure could affect all residents who were transferred or discharged to another facility at risk of having their discharge rights violated. Findings included:Record review of Resident #1 Face Sheet. dated 02/15/2025 revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that include Parkinsonism, Depression and Schizoaffective Disorder. Record review of Resident #1 MDS assessment dated [DATE] reflected the resident had a BIMS score of 14 indicating no cognitive impairment. Section Q 0400 reflects no Discharge plan in place. Section Q0610 reflects that there was no referral made…

    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 · Ecited before2025-09-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    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 residents who needed respiratory care ,including tracheostomy care and tracheal suctioning, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure physician's orders were written for oxygen use via nasal canula for Resident #1 on readmission [DATE] to 09/16/2025. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to…

    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 before2025-09-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, and Resident #2) of 11 residents reviewed for ADLs. The facility failed to ensure:- Resident #1 had his fingernails cleaned and trimmed.- Resident #2 had his fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. 1- Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma…

    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 · D2025-09-16 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 be adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 11 residents (Resident #1) reviewed for reasonable accommodations. The facility failed to ensure the call light in the resident room, used by Resident #1, was always within reach. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition…

    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 · E2025-06-11 · tag F0850 — failed to provide social-work services — pattern
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. 1. The facility, licensed for 144 beds, did not employ a full-time social worker from 3/26/25 to 6/11/25. This failure could place residents at risk of social service and psychosocial needs not being met. The findings included: Record review of the facility's Daily Census Report, dated 6/10/25, noted the facility had a total licensed bed capacity of 144. Record review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) date 06/06/25 noted the facility had a total licensed capacity of 144 beds. Record review of an undated document titled Job Details reflected the Previous Social Worker was employed from 7/11/23 to 3/26/25. In an interview on 6/10/25 at 2:37 PM, ADON B stated the facility did not have a social worker and had not had a social worker since the end of March. ADON B stated the Previous Social Worker left on vacation…

    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
Show the remaining 16 citations
  • Potential for harm · Ecited before2024-12-20 · tag F0656 — failed to write and follow a full care plan — pattern
    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 that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for 1 (Resident #55) of 6 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #55 had a person-centered care plan to include significant advance directive code status change from full code to DNR code, when they received Resident#55 consent on [DATE]. This failure could place resident at risk of been resuscitated and not honoring her DNR wishes. Findings included: Review of Resident #55's face sheet dated [DATE] revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses including hypertension (High blood pressure), Non-Alzheimer's Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease…

    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 · Ecited before2024-12-20 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #35, Resident #45, Resident#24, and Resident#40) of 16 residents reviewed for ADLs. The facility failed to ensure: - Resident #35 had her fingernails cleaned and trimmed. - Resident #45 had her fingernails trimmed. - Resident #24 had her fingernails cleaned and trimmed. - Resident #40 had her fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1- Resident #35 Record review of Resident # 35's Face Sheet dated, 12/18/24, reflected a [AGE] year-old female admitted to the facility with initial admission date of 10/2/2017 with relevant diagnoses of Alzheimer's (brain disorder that gradually decreased memory function),…

    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 · Ecited before2024-12-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure food items in the facility kitchen were covered. This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 12/17/24 at 7:58 AM of the walk-in refrigerator revealed sausages were left open in a cardboard box. Observation on 12/17/24 at 8:03 AM of the dry storage area in the kitchen revealed a box of pasta and a box of cream of wheat were left uncovered. In an interview on 12/18/24 at 1:52 PM, the Dietary Manager stated the cooks were mainly responsible for covering all food items in the kitchen. He stated that his expectation was all food items in the kitchen should be covered appropriately even if the food items were in a box. He stated the risk to residents of not covering food items could…

    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 · D2024-12-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 observations, interviews and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents (Resident #60) reviewed for reasonable accommodations. The facility failed to ensure the call light in resident room [ROOM NUMBER] A used by Resident #60 was always within reach. This failure could place resident at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Review of Resident #60's face sheet dated [DATE] reflected she was an [AGE] year-old female with an admission date of [DATE]. admission diagnoses reflected Resident #60 had a diagnosis of type 2 diabetes, fracture of shaft of left ULNA (fracture of left forearm), cognitive communication deficit (a condition makes it difficult to communicate). Review of the current diagnosis dated [DATE] reflected resident #60 was diagnosed with…

    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 before2024-12-20 · 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 maintain an infection control program designed to prevent the development and transmission of infection for 1 (Resident #51) of 6 residents observed for infection control. The facility failed to ensure: CNA E donned the appropriate PPE (Personal Protective Equipment) during the transfer of Resident #51 who was on enhanced barriers precautions r/t having an indwelling foley catheter. This failure could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: Review of Resident #51's MDS, dated [DATE], revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His BIMS score was 09 out of 15 which indicated moderate cognition impairment. His diagnoses included obstructive uropathy (occurs when urine cannot drain through the urinary tract), diabetes mellitus (high sugar level in the blood), and Non-Alzheimer's Dementia (loss of intellectual functioning, especially with…

    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 · Ecited before2024-10-23 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for two of eight residents (Resident #3 and Resident #4) reviewed for ADL care. The facility failed to ensure Resident #3, and Resident #4 had her fingernails trimmed and cleaned. This failure could place residents at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Record review of Resident #3's admission MDS assessment, dated 09/11/2024, reflected Resident #3 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included left-sided hemiplegia (paralysis of left side of the body), Stroke, hypertension (high blood pressure), Gastro esophageal reflux disease (stomach contents leak into the esophagus), hyperlipidemia (high blood lipid levels), Seizure disorder. Resident #3 had a BIMS score of 15,…

    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 · D2024-10-23 · 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 observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #2) of four residents reviewed for abuse. The facility failed to protect Resident #2 from physical abuse by HA B. On 2/16/24 at 9:45 PM , HA B physically grabbed snacks from Resident #2, then proceeded to grab his arm and became involved in a physical interaction of tugging items back and forth with Resident #2 until Resident #2 fell on the ground without any physical injuries or harm. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 02/16/24 at 9:45 PM and ended on 02/23/24. The facility had corrected the noncompliance before the Incident investigation began on 10/22/24. The facility terminated HA B on 02/16/24, with no other incidents that involved Resident #2, and staff were reeducated regarding Abuse and Neglect on 02/16/24 through 02/20/24. This failure could place residents at risk of serious injury and harm. Findings included: Record…

    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
  • Potential for harm · Dcited before2024-10-23 · 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 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 one (Residents #1) of seven residents observed for infection control. CNA A failed to perform hand hygiene during incontinence care for Resident #1. This failure could place residents at risk for the development and/or worsening of urinary tract infections, cross contamination, and skin breakdown. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old-female admitted to the facility on [DATE]. Her BIMS score was 15 out of 15 which indicated she was cognitively intact, required extensive, one-person assistance for ADLs and was always incontinent of bowel and bladder. Her diagnoses included hypertension (high blood pressure), Seizure or Epilepsy (a chronic brain disease…

    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 · Ecited before2023-10-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure dish machine reached minimum of 120 degrees F for wash and rinse on 10/24/23. 2. The facility failed to ensure food in the kitchen's refrigerator and freezer were stored in sealed containers, labeled, and dated. The facility failed to ensure food item in refrigerator was not spoiled. 3. The facility failed to maintain cleanliness of the inside of the ice machine. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observations on 10/24/23 at 10:07 AM revealed the Dietary Manager ran the dish machine with first two wash/rinse low temperature dish machine reading 100 temp F for wash and rinse. The third time dish machine ran cycle the temperature only reached 110 temp F for wash and rinse. Dietary Manager ran the dish machine two more times with 115 temperature F and 118…

    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 · D2023-10-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living 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 observations, interview and record review, the facility failed to provide a safe, clean, and homelike environment for 2 (Residents #188 and #84) of 24 residents reviewed for environment. The facility failed to provide Residents #188 and #84 a handwashing sink that was not loose and a paper towel dispenser that worked properly without cover coming off in resident bathroom. This failure could place residents at risk for living in an unsanitary and uncomfortable environment. Findings included: Review of Resident #188's face sheet dated 10/26/23 reflected Resident #188 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of displace avulsion fracture of right talus (broken bone in ankle), hypertension, diabetes, post-traumatic stress disorder, neuropathy, and heart disease. Review of Resident #188's other MDS assessment dated [DATE] reflected Resident #188 had a BIMS score of 15 indicating he was cognitively intact. Observation and Interview on 10/24/23 at 10:55 AM with Resident #188…

    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 before2023-10-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #12 and Resident#30) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #12 had her fingernails cleaned and trimmed. 2- Resident #30 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #12's Quarterly MDS assessment dated [DATE] reflected Resident #12 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis that affects only one side of the body), muscle weakness, lack of coordination, and type 2 diabetes mellitus. Resident #12's BIMS score was 15, which indicated her cognition was intact. The MDS assessment…

    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 before2023-10-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for one (Resident #80) of three residents reviewed for respiratory care. The facility failed to have Resident #80's oxygen humidifier replaced weekly as ordered. This failure could place residents at risk for infection. Findings include: Review of Resident #80's Quarterly MDS assessment, dated 10/17/2023, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #80's BIMS score was a 15 which reveals an intact cognition. His active diagnoses included anemia, high blood pressure, and anxiety disorder. The MDS had oxygen therapy checked under his specialty treatment section. Review of Resident #80's Physician orders summary dated 10/24/2023, reflected, . Change O2 tubing and humidifier bottle. every night shift every Wed Ensure that tubing is dated when changed .order date 9/18/23 . Review…

    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 before2023-10-26 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 (Nurses cart halls 200/300 and Med Aide cart hall 300) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1- MA E, responsible for Med Aide cart hall 300, counted controlled drugs every shift change. 2- Medications in unsecure containers were immediately removed from stock. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1- Record review and random count observation of hall 300 Med Aide cart with MA E on 10/24/2023 at 11:51 AM revealed missing signatures for Off duty and On duty for 10/16/2023, 10/17/2023, 10/22/2023 of the narcotic count 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled 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 observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (200/500 hall Nurse Medication cart) of 3 medication carts reviewed for pharmacy services and 1 medication room of 1 reviewed for storage in that: The facility failed to ensure: 1- The 200/500 Hall Nurse Medication cart had a control solution expired. 2- Two vials of TB serum (used to test if you have a tuberculosis germs in the body) that were opened and used were dated in the medication room refrigerator. These failures could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: 1- Record review and observation on [DATE] at 12:48 PM of hall 200/500 Nurse cart with LVN C revealed an expired blood glucose control solution…

    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 before2023-10-26 · 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 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 one (Residents #238) of four residents reviewed for infection control. The facility failed to ensure CNA A wore an N95 facemask, gown, gloves, and goggles or a face shield upon entering Resident #238's room who was on droplet isolation (used to prevent the spread of pathogens that are passed through the respiratory secretions ). This failure could place residents at risk for the spread of infection through cross-contamination of pathogens and illness. Findings included: Record review of the facility's policy titled, Transmission- Based (Isolation) Precautions, dated 10/24/2022, reflected .9. Droplet Precautions- a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with…

    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 · Dcited before2023-08-02 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) for 1 of 5 residents (Resident #1) reviewed for medication administration. The Facility failed to ensure Resident #1 had received his medications as scheduled and as ordered by his physician. This failure could place residents at risk of health complications. Findings included: Record review of Resident #1's Face Sheet, dated 08/01/23, revealed he was a 67 -year-old male admitted on [DATE]. Relevant diagnoses Type 2 Diabetes Mellitus (high blood glucose), Major Depressive Disorder, Acute Kidney Failure, and Essential Hypertension (high blood pressure). Record review of Resident #1's Minimum Data Set (MDS) on dated 05/24/23 revealed she had a Brief Interview for Mental Status (BIMS) score of 03 (severely mentally impaired and was not interviewable) and for Active Diagnosis, Resident #1 had diagnosis of Hypertension (high…

    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

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ADVANCED HEALTHCARE SOLUTIONS — 28 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 →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 2 of 52.0≈ chain avg
Quality measures 5 of 54.0+1.0 vs chain
The other 27 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Advanced Health & Rehab Center of GarlandGarland, TX 1 of 5Advanced Rehabilitation and Healthcare of AthensAthens, TX 1 of 5El Paso Health & Rehabilitation CenterEl Paso, TX 1 of 5Greenville Health & Rehabilitation CenterGreenville, TX 1 of 5Tomball Rehab & NursingTomball, TX 1 of 5Winfield Rehab & NursingCrockett, TX 2 of 5Advanced Rehabilitation & Healthcare of BurlesonBurleson, TX 2 of 5Balch Springs Nursing HomeBalch Springs, TX 2 of 5Henderson Health & Rehabilitation CenterHenderson, TX 2 of 5Heritage House at Paris Rehab & NursingParis, TX 2 of 5McAllen Nursing CenterMcAllen, TX 3 of 5Clarksville Nursing CenterClarksville, TX 3 of 5Palo Pinto Nursing CenterMineral Wells, TX 3 of 5Prairie House Living CenterPlainview, TX 3 of 5Santa Fe Health & Rehabilitation CenterWeatherford, TX 3 of 5Sulphur Springs Health And RehabilitationSulphur Springs, TX 3 of 5The Renaissance At Kessler ParkDallas, TX 3 of 5Whitehall Rehab & NursingCrockett, TX 3 of 5Willow Rehab & NursingKilgore, TX 4 of 5Advanced Rehabilitation And Healthcare Of VernonVernon, TX 4 of 5Advanced Rehabilitation and Healthcare of WichitaWichita Falls, TX 4 of 5Crowell Nursing CenterCrowell, TX 4 of 5Whispering Oaks Rehab & NursingCuero, TX 5 of 5Advanced Rehabilitation And Healthcare Of BowieBowie, TX 5 of 5Clyde Nursing CenterClyde, TX 5 of 5Heritage House At Keller Rehab & NursingKeller, TX 5 of 5Seymour Rehabilitation And HealthcareSeymour, TX

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

Owner / managerTypeRoleSince
HOOPER, GRADYIndividualCORPORATE OFFICERsince 03/01/2024
MESQUITE HC SNF LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2024
SCHEINER, ELIEZERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/29/2024
SILBERSTEIN, ARIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/29/2024
ELLENBOGEN, MOSSIndividualTRUSTEE OF THE SNFsince 03/01/2024
434 PAZA DRIVE LLCOrganizationADP OF THE SNFsince 02/18/2025
BRASS TX TRUSTOrganizationADP OF THE SNFsince 02/18/2025
GOLD TX TRUSTOrganizationADP OF THE SNFsince 02/18/2025
RED BRASS HOLDCO LLCOrganizationADP OF THE SNFsince 02/18/2025
SILVER TX TRUSTOrganizationADP OF THE SNFsince 02/18/2025
BEASLEY, GENETTAIndividualADP OF THE SNFsince 03/01/2024
PRASAD, JYOTSNAIndividualADP OF THE SNFsince 02/18/2025

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

6 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.

$7.1M
Net patient revenuemost recent cost report
+4.9%
Operating marginrevenue minus expenses
$230K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 3%Other / private 23%

About 74% 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. This home reported $230K paid to related parties (affiliated landlords or management companies) in its most recent 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

$237per resident / day
operating cost
$7,212per month
≈ monthly operating cost
$249per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675033. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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