Mission Nursing and Rehabilitation Center
1013 S. Bryan Rd., Mission, TX 78572 · For profit - Limited Liability company · 170 certified beds · (281) 419-5520 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,190 in federal fines (most recent 2023-10-06)
- its payroll-based staffing rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.0% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 3.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.5% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.3% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.8% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.4% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 0.6% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.1% | 9.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.1% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.1% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.58 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.02 | 2.06 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
54.5% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.1% 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 36 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.5%CMS range 43.5–66.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.2–16.0 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 61.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 63.3% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.1–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.76 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 170 beds and averages 97.5 residents a day — about 57% occupied, or roughly 72 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 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 2.96 hrs/resident/day on weekends vs 3.61 on weekdays — 18% thinner on weekends. RN hours go from 0.51 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below 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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2023-10-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision for one resident (Resident #49) of three residents reviewed for supervision and ensured the environment remained free of accident hazards for 2 of 2 unlocked resident rooms reviewed for supervision in that. 1) The facility failed to ensure Resident #49 received supervision while in the shower. 2 ) The facility failed to ensure the two resident rooms, 323 and 324 were free of cluttered storage of equipment, furniture, boxes, walkers, wheelchairs in a secured manner. These failures could place residents at risk of being in an unsafe environment and at risk for accidents and injury. Findings included: 1)Record review of Resident #49's admission Record dated 10/06/23 revealed a [AGE] year old male with an admission date of 6/01/22 and diagnoses which included: dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment 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.
- Potential for harm · E2026-04-02 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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 observation, record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #13) reviewed for pharmacy services. The facility failed to ensure Resident #13 received the correct dose of:Amiodarone HCI oral tablet 200 mg, Apixaban oral tablet 2.5 mg, and Metoprolol Tartrate Oral Tablet 25 mg. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #13's admission record, dated 03/18/26, reflected a [AGE] year-old female with an admit date of 02/16/26 and an initial admission date of 02/03/24 with diagnoses that included encephalopathy ( any condition that disrupts normal brain function), dependence on renal dialysis (a life-sustaining need regular hemodialysis due to end-stage renal disease or acute kidney failure where the kidneys cannot adequately filter waste or remove fluid), angina pectoris (chest…
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.
- Potential for harm · D2026-04-02 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 complete the baseline care plan for one (Resident #89) of three residents reviewed for base line care plans. The facility failed to provide Resident #89 a written summary of his baseline care plan completed within 48 hours of admission. This failure placed three newly admitted residents reviewed at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Finding include: Record review of Resident #89's face sheet, dated 3/18/26 reflected she was a [AGE] year-old female with an admission date of 3/4/26. Her diagnoses included chronic obstructive pulmonary disease (a progressive, treatable, but incurable lung disease that causes chronic airflow restriction, making it hard to breath). Record review of Resident #89's MDS revealed that was still in progress. Record review of Resident #89's baseline care plan reflected…
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.
- Potential for harm · Dcited before2026-04-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #38) of 6 residents reviewed for comprehensive care plans. The facility failed to include Resident #38's enhanced barrier precautions in his care plan. This failure could place residents at risk of not receiving the appropriate care, services or treatment needed in a timely manner.Findings included: Record review of Resident #38's face sheet, dated 03/17/2026, reflected a 57 -year-old male admitted [DATE]. Resident #38's diagnoses included peripheral vascular disease (a slow, progressive circulation disorder where blood vessels outside the heart and brain) and wound to left heel. Record review of Resident #38's Quarterly MDS assessment, dated…
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.
- Potential for harm · D2026-04-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 resident (Resident#10) reviewed for indwelling catheters. The facility failed to prevent Resident#10's urinary catheter tubing (bag) from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections. Findings included: Record review of Resident#10's face sheet with a date 3/18/26 revealed a [AGE] year-old male originally admitted on [DATE]. Resident#10 had admitting diagnosis of neuromuscular dysfunction of the bladder, unspecified (a loss of bladder control caused by nerve damage from diseases or injuries like stroke, diabetes or spinal cord damage). Record review of Resident #10's care plan dated 3/3/2026 revealed Resident #10 has a indwelling catheter due to obstructive uropathy kidney neoplasm(a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 7 residents (Resident #71) reviewed for pharmacy services. The facility failed to compare the instructions written on Resident #71's blister pack with the physician's order for Gabapentin before it was administered on 03/19/2026. This deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.Record review of Resident #71's face sheet, dated 03/19/26, revealed a [AGE] year-old female admitted on [DATE] and readmitted [DATE]. The diagnoses included Cirrhosis of the liver (chronic condition of the liver in which the normal functioning tissue is replaces with scar tissue and regenerative nodules as a result of chronic liver failure), Bipolar Disorder (a chronic mental health condition characterized…
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.
- Potential for harm · Dcited before2026-04-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 ensure all drugs and biologicals were labeled and stored appropriately for 1 of 3 residents (Resident #28) reviewed for labeling and storage. The facility failed to put an open date for Resident #28's Trelegy inhaler. This failure could have placed residents at risk of not receiving the therapeutic effects of the medication. The findings included: Review of Resident #28's admission Record, dated 3/19/26, revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnosis including Chronic obstructive pulmonary disease with exacerbation (a sudden worsening of symptoms typically increased shortness of breath, cough, and thicker or discolored mucus). Review of Resident #28's Care Plan dated 1/7/26 revealed: Revised on 5/9/25 Focus: Resident #28 has Emphysema/ Chronic obstructive pulmonary disease related to Physiological atrophy. Review of Resident #28's quarterly MDS Assessment, dated 1/9/26 revealed her…
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.
- Potential for harm · Dcited before2026-04-02 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 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 1 of 6 (Resident #38) residents reviewed for infection control. The facility failed to ensure Resident #38 had an EBP sign on the door. This failure could place residents at risk for healthcare associated cross-contamination and the spread of infection.Findings included: Record review of Resident #38's face sheet dated 03/17/2026 reflected a 57 -year-old male, admitted on [DATE]. Resident #38's diagnoses of Peripheral Vascular Disease (a slow, progressive circulation disorder where blood vessels outside the heart and brain) and wound to left heel. Record review of Resident #38's Quarterly MDS assessment, dated 10/10/2025, reflected he scored a 2 on his BIMS which reflected severely cognitively impaired. Record review of Resident…
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.
- Potential for harm · Dcited before2026-01-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles in 1 of 4 medication carts (700 hall medication cart) reviewed for medication storage. The facility failed to ensure the medication aide medication cart for 700 hall was secured by a lock when it was left unattended by MA A. This failure could place residents at risk of injury if medication left unsecured was consumed. Findings include:Findings include: During an observation on 1/2/2026 at 5:00 PM the 700 Hall medication aide medication cart was left unlocked and unattended on 700 hallway. MA A approached the medication cart and noticed it was unlocked and secured the cart by locking it. There was no one around the medication cart while MA was inside a room. During an interview on 1/2/2026 at 05:05 PM MA A revealed she was responsible for the medication cart that was left unlocked. She stated she was expected to lock the medication cart when she walked away from it. She…
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.
- Potential for harm · D2025-01-08 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (R#22) of 4 residents whose records were reviewed for OOH-DNR Order forms: The facility failed to have the physician sign at the bottom of R#22's Out of Hospital Do Not Resuscitate (OOH-DNR) order, which mad the advance directive invalid. This failure could place residents at risk for not having their end of life wishes honored. The findings included: Record review of R#22's admission record dated 01/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and an initial admission date of 02/12/20. Her diagnoses included Dementia (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), and Crohn's disease (inflammatory bowel disease that causes swelling and irritation of the tissues in the digestive tract). Record review of R#22's quarterly MDS assessment dated…
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.
- Potential for harm · Dcited before2025-01-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #34) reviewed for respiratory care. The facility failed to ensure Resident #34 received oxygen at the prescribed rate. This failure could place residents at risk for respiratory distress. The findings included: Record review of Resident #34's face sheet dated 1/6/25 reflected the resident was an 81 -year-old male admitted to the facility on [DATE]. Resident #34 had diagnoses which included the following: acute (rapid onset) and chronic (persistent and long-lasting) respiratory failure, acute bronchitis (inflammation of the bronchial tubes in the lungs), and chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). Record review of Resident #34's MDS…
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.
Show the remaining 13 citations
- Potential for harm · D2025-01-08 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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 interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 (CNA D) of 4 CNAs reviewed for competent nursing care. The facility failed to ensure CNA D communicated R#22's change of condition to the charge nurse on 12/23/2024. This failure could place residents at risk of not having change in conditions assessed immediately resulting in delayed treatment and a decreased in quality of life. The findings included: Record review of R#22's admission record dated 01/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and an initial admission date of 02/12/2020. Her diagnoses included Dementia (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), and Crohn's disease (inflammatory bowel disease that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 interview and record review, the facility failed to provide pharmaceutical services including procedures that ensure accurate administering of all drugs and biologicals to meet the needs for 2 of 10 (Resident #5 and Resident #22) residents reviewed for pharmacy services. 1. The nursing staff did not administer Resident #5's Tramadol as prescribed by her physician. This failure could place resident s with pain at risk of not receiving the intended therapeutic benefit of their medications. 2. MA documented she had administered Resident #22 a frozen nutritional treat on 01/07/2025 when the facility did not have the frozen nutritional treat available on 01/07/2025. This failure could place residents at risks of not receiving the intended therapeutic benefit of their medications. The findings were: Record review or Resident #5's admission Record dated 01/08/25 revealed an [AGE] year-old female with an initial admission date of 04/09/24 with diagnoses of Alzheimer's disease (a progressive irreversible brain…
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.
- Potential for harm · Dcited before2025-01-08 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 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 5 residents (Resident #32) observed for infection control issues in that: CNA F and CNA G revealed CNA F used wipes to cleanse the perineal area, folding it, and using the wipes again and CNA G noticed not sanitizing between glove changes. This deficient practice could place residents at-risk for infection due to improper hand sanitizing and incontinent care practices. The findings were: Record review of Resident #32's electronic face sheet dated 1/8/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included unspecified sequelae of cerebral infarction (long-term complications from a stroke where specific nature cannot be clearly identified), muscle weakness, muscle…
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.
- Potential for harm · D2024-09-06 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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 interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 4 residents (Resident#2) reviewed for abuse and neglect, in that: Facility staff member, CNA A did not implement their abuse policy related to reporting suspected abuse when Resident #2 was observed to be crying while Resident #2's family member was rubbing her forehead. This failure could place residents at risk of abuse and neglect. The findings were: Record review of Resident #2's face sheet, dated 09/06/24, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer disease, unspecified (progressive disease that destroys memory and other important mental functions), essential (primary) hypertension (high blood pressure), functional quadriplegia (a condition that causes complete immobility due to a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-28 · tag F0839 — isolatedEmploy staff that are licensed, certified, or registered in accordance with state laws.
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 professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 30 staff (LVN A) reviewed for staff qualifications. The facility failed to ensure LVN A renewed her nursing license before the expiration date in order to practice nursing in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly licensed. The findings included: Record review of the Texas Board of Nursing website license verification portal on [DATE] at 5:44 p.m. revealed LVN A's Texas nursing license was listed as delinquent with a license expiration date of [DATE]. Record review of the Texas Board of Nursing website on [DATE] stated, If you do not renew your license before the expiration date, your license will go into delinquent status, and you cannot practice/work as a nurse with a delinquent license. You will not be able to practice nursing until…
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.
- Potential for harm · D2024-05-14 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation that involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (R #1) of 5 residents reviewed for abuse/neglect. The facility failed to report allegations of resident abuse for R #1 for an incident on 04/24/24 to the State Survey Agency within the allotted time frame of 2 hours. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect. The findings included: Record review of R #1 's file reflected [AGE] year-old female with original admission date of 09/08/23 and last admission date of 03/12/24. Her diagnosis included: Alzheimer's disease, cognitive…
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.
- Potential for harm · Dcited before2023-12-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 record review and interview the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 5 residents (Resident #1) reviewed for quality of care, in that: The facility failed to ensure Resident #1 medication Ipratropium-Albuterol Solution via nebulizer mask was monitored by staff based on their nursing protocols. This failure could place residents at-risk of not receiving adequate respiratory care. The findings included: Record review of Resident #1's admission record, dated [DATE], reflected he was a [AGE] year-old male with an admission date of [DATE] with diagnoses which included dementia (decline in cognitive abilities), chronic obstructive pulmonary disease with acute exacerbation (progressive lung disease and airflow limitation), contracture (shortening of muscles,…
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.
- Potential for harm · Dcited before2023-12-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 maintain clinical records on each resident that were complete and accurate, for one Resident (R#1), of five residents reviewed for clinical records, in that. The facility failed to ensure LVN E documented the results of vital sign assessments accurately in Resident #1's clinical records. This failure could place residents at risk for not receiving proper care and treatments. The findings included: Record review of Resident #1's admission record, dated 12/28/23, reflected he was a [AGE] year-old male with an admission date of 12/16/23 with diagnoses which included dementia (decline in cognitive abilities), chronic obstructive pulmonary disease with acute exacerbation (progressive lung disease and airflow limitation), contracture (shortening of muscles, tendons, skin causing joints to shorten), gastrostomy status (artificial external opening into stomach for nutritional support), and aphasia (damage to the language areas of the brain.) Record review 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.
- Potential for harm · Fcited before2023-10-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread for 1 of 1 facility. The facility failed to have a system in place for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella could grow and spread. This deficient practice places the facility residents at risk for airborne infections. The findings included: Interview on 10/05/23 with the Maintenance Director at 10:10 a.m., he stated he did not know what Legionnaire's was. He stated he had been working at the facility for 2 years. Stated the only thing he checks every week is the water temperatures. Stated to his knowledge, there is no system to monitor effectiveness of control measures. Stated he had training upon hire from the previous maintenance director but not on anything regarding checking for bacteria in the facility water. He is…
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.
- Potential for harm · D2023-10-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 consult with the resident's physician when there was a significant change in the resident's physical mental or psychological status for 1 of 5 residents (Resident #30) reviewed for notification of change of condition. The facility failed to notify the resident's physician when Resident #30's appointment with the orthopedic surgeon was scheduled on 12/27/22, after an acute left femoral neck fracture was identified on x-ray dated 12/18/22. This failure could affect residents with injuries by placing them at risk of delay medical treatment, hospitalization, and decline in condition. The findings included; Record review of the admission record for Resident #30 dated 10/06/23 reflected Resident #30 was an [AGE] year-old female that was admitted to facility on 03/14/22 with the diagnoses including Alzheimer's Disease (a progressive mental deterioration due to generalized degeneration of the brain), type 2 diabetes mellitus (chronic condition that affects 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.
- Potential for harm · Dcited before2023-10-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 the resident's comprehensive care plan for one (Resident #60) of 18 residents reviewed for care plans that describe the services to be provided to attain the resident's highest practicable physical, mental, and psychological well-being in that: The facility failed to develop a care plan to address Resident #60's feeling anxious when door was closed during incontinent care. Resident #60 would refuse to have the door closed while staff provided care. This failure could affect the residents with behavioral healthcare needs at risk for their psychosocial needs not being met. The findings included: Record review of Resident #60's Face Sheet dated 10/06/23 indicated Resident #60 was an [AGE] year-old male admitted to facility on 03/13/21 and readmitted on [DATE] with diagnosis of vascular dementia a decline in thinking skills caused by conditions that block or reduce the blood flow to various regions of the brain, depriving them 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.
- Potential for harm · Dcited before2023-10-06 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observations, interviews, and record reviews the facility failed to ensure and 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 of 4 ( Resident #291 and Residents #23) residents reviewed for pharmaceutical services, in that: 1. MA J did not check open date on 2 multi dose medication bottles and was going to administer them to Resident #291. 2. Resident #23's medication (zinc oxide 20%) was found on the bedside dresser drawer. These deficient practices could place residents at risk of not receiving the intended therapeutic effect of the medications resulting in exacerbation of the resident's condition and disease process. Findings included: 1. Record review of Resident #291's face sheet dated 10/06/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of left femur (thigh…
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.
- Potential for harm · Dcited before2023-10-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 clinical records on each resident that were complete and accurate, for one Resident (R# 81), of eight residents reviewed for clinical records, in that. LVN did not document the results of two skin assessments for pressure ulcers in the sacrum and in left heel in Resident #81's clinical records. This failure could place residents at risk for not receiving proper care and treatments. The findings were: Record review of Resident #81's admission record dated 10/05/23 reflected Resident #81 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident #81 was an [AGE] year-old female with diagnoses that included pressure ulcer of the sacral region (triangular bone at botom of the spine) stage 4 (a full-thickness tissue loss with exposed bone, tendon, or muscle), diabetes (sustained high blood sugar levels), and pressure ulcer of left heel (localized damage over a bony area.) Record review of Resident #81'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.
“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.
- 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.
Fines & penalties
$8,190 in federal fines across 1 penalty.
- $8,190 — penalty dated 2023-10-06
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 HMG HEALTHCARE — 31 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 30 homes this chain runs (chain average 3.1★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| STRAMECKI, ANTHONY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2016 |
| VRATIS, KACEY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2016 |
| WAY, GEORGE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2013 |
| MURRELL, EDWARD | Individual | CORPORATE OFFICER | since 11/01/2012 |
| ROLLO, JEFFERY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2012 |
| HMG PARK MANOR OF MISSION, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2021 |
| WINNIE-STOWELL HOSPITAL DISTRICT | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2021 |
| CULP, ROLAND | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
| DASPIT, LAURENCE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
| PICO, ANA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/04/2021 |
| PRINCE, DEREK | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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
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.
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 455761. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, 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 →
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