Shady Oak Nursing And Rehabilitation
101 S Lancaster, Moulton, TX 77975 · For profit - Corporation · 61 certified beds · (361) 596-7373 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0570)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (100%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 improved from 4 to 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 | 8.7% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.9% | 3.0% | 5.4% | better |
| 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 | 2.0% | 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 | 6.6% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.5% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.8% | 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 | 4.0% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.4% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 25.7% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.1% | 12.3% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.48 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.56 | 2.06 | 1.80 | worse |
‡ 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.
27.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 27.5%CMS range 17.6–40.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 7.2–16.8 | 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 | not 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 discharge | not 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 discharge | not 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 identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.34 | 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 61 beds and averages 33.3 residents a day — about 55% occupied, or roughly 28 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 2.85 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.39 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 2.42 hrs/resident/day on weekends vs 3.02 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.34 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 100% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
14 citations, most serious first — scroll within the box to see all.
- Potential for harm · Ecited before2025-09-05 · tag F0880 — failed to prevent and control infections — patternProvide 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, interviews, and record reviews, 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 disease and infection for 3 of 5 residents (Residents #4, #7 and #21) reviewed for infection control, in that: 1. The facility failed to maintain correct infection control when, while providing wound care for Resident #4, LVN C failed to use proper protective equipement. 2. The facility failed to maintain correct infection control when, while observing Resident #7's room, a reusable urinal was seen hang uncovered and hanging from the resident's trash can. 3. The facility failed to maintain correct infection control when, while providing incontinent care for Resident #21, NA A did not change her gloves or wash hands after touching the resident's trash can. These deficient practices could place residents at-risk for infection due to improper care…
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 · D2025-09-05 · 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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Resident #21) reviewed for incontinent care, in that: The facility failed to provide appropriate treatment and services to prevent urinary tract infection by having CNA B using a back to front motion to clean Resident #21's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.The findings were: Record review of Resident #21's face sheet, dated 09/04/2025, revealed an admission date of 02/25/2022, and, a readmission date of 07/08/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Mood disorder (conditions that affect a person's emotional state), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism…
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 · D2025-09-05 · tag F0801 — isolatedEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements, in that:The Dietary Supervisor did not have the appropriate certification, education, or qualification to serve as the Director of Food and Nutrition Services.This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.The findings were:During an interview with the Dietary Supervisor on 09/02/2025 at 10:30 a.m., he stated that he was not certified as a Dietary Manager, and that he was enrolled in a course scheduled to begin 09/04/2025. During an interview with the Administrator on 09/05/2025 at 1:15 p.m., the Administrator confirmed the Dietary…
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 before2025-09-05 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 provide a safe, clean, and comfortable environment for residents, staff and the public in 1 of 3 (South Wing) shower rooms reviewed, in that: The toilet in the South Wing shower room was loosely affixed to the floor. This deficient practice could place residents who utilized the toilet in the South Wing shower room in danger of falling. The findings were: Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff and the public in 1 of 3 (South Wing) shower rooms reviewed, in that: The toilet in the South Wing shower room was loosely affixed to the floor. This deficient practice could place residents who utilized the toilet in the South Wing shower room in danger of falling. The findings were: Observation of the South Wing shower room on 09/02/2025 at 1:42 p.m. revealed that the toilet was loosely affixed to the floor and was able to be moved approximately three inches away from center. During an interview with RN E on…
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 · Ecited before2024-08-08 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 shower rooms reviewed, in that: 1. The South Hall shower room had a strong foul odor. 2. The temperature in the facility kitchen was 95.1 degrees Fahrenheit. These deficient practices could place residents at risk and result in an environment that is not safe, functional, sanitary, or comfortable for residents, staff, and visitors. The findings were: Observation on 08/05/2024 at 10:42 a.m. revealed a strong foul odor was emanating from the shower room in the South Hall. During an interview with CNA C on 08/05/2024 at 10:42 a.m., CNA C confirmed a strong foul odor was emanating from the shower room in the South Hall. During an interview with LVN D on 08/05/2024 at 10:44 a.m., LVN D confirmed a strong foul odor was emanating from the shower room in the South Hall. Record review of the facility policy, Deep Cleaning Process - Bathroom/Showers, undated, revealed, Follow the cleaning process in 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 before2024-08-08 · 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
Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 3 residents (Resident #23) reviewed for infection control, in that: CNA B failed to wash or sanitize her hands or change her gloves after touching the remote of Resident #23's bed before starting incontinent care. After cleaning Resident #23's genitals, CNA B let the soiled briefs get in contact with the resident's genitals. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #23's face sheet, dated 08/07/2024, revealed an admission date of 11/14/2022 and, a readmission date of 06/15/2023, with diagnoses which included: Dementia (General decline in cognitive abilities), Neutropenia (low concentration of neutrophils (white blood cell) in the blood making it harder to fight infection),…
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 · F2023-07-14 · tag F0570 — widespreadAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 facility review for the surety bond, in that: The facility's surety bond was not enough to match the total residents' trust fund account balance. This failure could place residents who deposit personal funds with the facility at-risk of their personal funds not being assured. The findings were: Record review of the facility's surety bond, dated 09/01/2022, revealed the bond amount was $15,000.00. Record review of the resident trust fund as of 07/14/2023, revealed the balance was $15,717.38. During an interview with the BOM on 07/14/2023 at 12:20 p.m., the BOM confirmed the total balance of the residents' trust fund accounts was $15,717.38 which exceeded the facility's $15,000.00 surety bond. The BOM stated she had just recently completed a trust audit and didn't know how it was missed. The ABOD stated the BOM was responsible for this task 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.
- Potential for harm · E2023-07-14 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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
Based on interview and record review the facility failed to develop and implement policies and procedures for screening through the employee misconduct registry to determine whether the individual is designated as unemployable for 10 of 18 staff (The DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator) reviewed for employment registry screenings, in that: The DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator did not have current employment registry screenings. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings were: Record review of the staff roster provided on 07/11/2023 by the facility revealed a hire date of 07/01/2022 for the DS, AD, MA A, CNA D, CNA E, MA F, [NAME] G, LVN I, RN J, and MDS Coordinator. In an interview with the HR Coordinator on 07/13/2023 at 10:07 a.m., the HR Coordinator revealed when the current corporation acquired the facility all staff were given a new hire date as of the date of acquisition. The HR Coordinator further revealed EMRs…
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 · E2023-07-14 · tag F0944 — patternConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR…
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 · E2023-07-14 · tag F0946 — patternProvide training in compliance and ethics.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide the required compliance and ethics training for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training requirements, in that: The facility failed to ensure compliance and ethics training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME]…
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 · E2023-07-14 · tag F0949 — failed to train staff on dementia and abuse — patternProvide behavior health training consistent with the requirements and as determined by a facility assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, [NAME] G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST,…
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 · D2023-07-14 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a significant change in the resident's status for 1 of 12 residents (Resident #10) reviewed for MDS assessments, in that: The facility failed to complete a Significant Change MDS for Resident #10 within 14 days after the resident was admitted to hospice services. This failure could place residents admitted to hospice services at-risk of not having their individual needs met. The findings were: Record review of Resident #10's face sheet, dated 07/13/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: hypertensive heart disease without heart failure (includes a number of complications of high blood pressure that affect the heart), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle weakness, difficulty in walking 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.
- Potential for harm · D2023-07-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #10 and #17) for care plan revisions in that: 1. The facility failed to ensure Resident #10's care plan was revised to include hospice services. 2. The facility failed to ensure Resident #17's care plan was revised to include may sleep in another room after an altercation with their roommate (Spouse) on 7/08/23. These failures could place residents at risk of not receiving care according to their needs. These findings were: 1. Record review of Resident #10's face sheet, dated 07/13/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: hypertensive heart disease (includes a number of complications of high blood pressure that affect the heart), dementia (group of symptoms affecting memory, thinking and social abilities severely…
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 · D2023-07-14 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 (Resident # 12) reviewed for hospice services. 1. The facility failed to obtain Resident #12's most recent hospice plan of care, signed hospice election form, and a physician's re-certification of the terminal illness. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #12's face sheet, dated 07/14/23, revealed a [AGE] year old female resident admitted to the facility on [DATE] with diagnoses: [Ascites] is a buildup 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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to CREATIVE SOLUTIONS IN HEALTHCARE — 149 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.1 | +2.9 vs chain |
| Health inspection | 5 of 5 | 2.7 | +2.3 vs chain |
| Staffing | 2 of 5 | 1.1 | +0.9 vs chain |
| Quality measures | 2 of 5 | 3.2 | -1.2 vs chain |
The other 148 homes this chain runs (chain average 2.1★, per CMS)
Showing 40 of 148; lowest-rated first.
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 |
|---|---|---|---|
| BOWERS, SEAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 07/01/2024 |
| CISNEROS, ALFRED | Individual | MANAGING CONTROL - GOVERNING BODY | since 02/18/2008 |
| COBB, TRAVIS | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/05/2022 |
| COOPER, STEPHEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/11/2022 |
| HARDIN, SHERRIE | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/04/2024 |
| KERZEE, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/24/2007 |
| KORENEK, PATRICIA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/05/2018 |
| SOECHTING, PAUL | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/22/2024 |
| STRACK, JOE | Individual | MANAGING CONTROL - GOVERNING BODY | since 02/11/2022 |
| HUGGINS, LINDA | Individual | CORPORATE DIRECTOR | since 09/01/2022 |
| WILLIG, ZACHARY | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| THOMPSON, JOHNNY | Individual | CORPORATE OFFICER | since 01/01/2025 |
| MOULTON I ENTERPRISES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/20/2025 |
| BLAKE, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2022 |
| BLAKE, MALISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2022 |
| HOUSER, HERBERT | Individual | ADP OF THE SNF | since 05/20/2025 |
| THOMAS, JOHN | Individual | ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 19 rows in the source record cover these 17 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.
1 organizational owner 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 676030. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, 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.