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Coronado At Stone Oak

19638 Stone Oak Parkway, San Antonio, TX 78258 · For profit - Limited Liability company · 112 certified beds · (210) 402-5750 Medicare & Medicaid certified

Call the home — (210) 402-5750 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Apr 2024
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
Worth asking about
  • 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
  • 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

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.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
19284 Stone Oak Pkwy · (210) 268-0124 · Call to confirm hours
Pharmacy
19239 Stone Oak Pkwy · (210) 314-6464 · Call to confirm hours
Grocery
Shahi0.4 mi
20323 Huebner Rd · (210) 481-2225 · Call to confirm hours
Park
Promontory Cir · Typically dawn to dusk
Place of worship
19291 Stone Oak Pkwy · (210) 490-6886

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

Quality measures — how residents actually fare

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased0.7%15.8%15.4%better
Long-stay residents who lose too much weight0.6%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.2%3.3%3.3%worse
Long-stay residents whose ability to walk worsened1.2%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.7%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers1.0%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control1.9%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table1.3%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better
Short-stay residents rehospitalized after admission26.9%25.7%22.6%worse
Short-stay residents with an outpatient ER visit8.6%12.3%12.0%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.

58.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 496 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.9%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
73.8%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 73.8% 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 371 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.9%CMS range 55.0–62.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 8.1–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge73.8%56.6%Oct 2024–Sep 2025CMS 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 discharge60.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge65.2%50.0%Oct 2024–Sep 2025CMS 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 identified95.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 5.1–9.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.51
RN hours/ resident / day
1.29
LPN hours/ resident / day
1.58
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.32
RN hoursweekends
27.0%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 112 beds and averages 103.0 residents a day — about 92% occupied, or roughly 9 beds typically open. It runs fairly full. 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 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.58 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 2.78 hrs/resident/day on weekends vs 3.62 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.58 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below 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

10
deficiencies at the latest standard inspection (2025-05-09)
4
at the previous standard inspection (2024-04-05)

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.

ABCDEFGHIJKL

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

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Ecited before2026-01-28 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 4 of 4 residents (Residents #1, #2, #3 and #4) reviewed for medical records. 1. The facility failed to ensure Resident #1's ADL-Bathing record recorded a bath or refusal for 1/19/2026, as noted on the electronic medical record. 2. The facility failed to ensure Resident #2's ADL-Bathing record recorded a bath or refusal for 1/2/2026 and 1/19/2026, as noted on the electronic medical record. 3. The facility failed to ensure Resident #3's ADL-Bathing record recorded a bath or refusal for 1/26/2026, as noted on the electronic medical record. 4. The facility failed to ensure Resident #4's ADL-Bathing record recorded a bath or refusal for 12/30/2026, 1/3/2026, 1/6/2026, 1/8/2026, 1/15/2026 and 1/24/2026, as noted on the electronic medical record. These failures could place…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #4) reviewed for quality of care. The facility failed to notify the physician when Resident #4 gained 3 pounds over night between the dates of 1/19/2026 and 1/20/2026) per the orders and facility policy. This failure could place residents at risk of harm, not receiving necessary medical care, and hospitalization.The findings include: Record review of Resident #2's admission Record, printed on 1/27/2026, reflected a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included heart failure (heart does not pump enough blood leading to fluid retention) and pneumonia (lung infection which may fill with fluid). 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-09 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 correct use of bed rails and to assess the resident for risk of entrapment from bed rails for 3 of 6 Residents observed for the use of side rails (Resident #1, Resident #13 and Resident #340). 1. Nursing staff failed to obtain an informed consent and assess Resident's #1 for the use of 1/4 side rails. 2. Nursing staff failed to obtain an informed consent for Resident #13 for the use of 1/4 side rails. 3. Nursing staff failed to obtain an informed consent and to assess Resident #340 for the use of 1/4 side rails. These deficient practices could affect any resident with bed side rails and could cause avoidable accidents. The findings were: 1. Review of Resident #1's quarterly MDS assessment, dated 12/13/24 revealed he was admitted to the facility on [DATE] with diagnosis including non-traumatic brain dysfunction. His BIMS score was 12 of 15 reflective of moderate cognitive impairment and he required substantial to maximum assistance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide an assessment that accurately reflected the resident's status for 1 (Resident #26) of 32 residents reviewed for assessment accuracy. The facility failed to reflect Resident #26 used a Bipap machine (bilevel positive airway pressure device or Type of respiratory support therapy that uses positive air pressure to help individuals breathe, especially individuals who have sleep apnea (a condition that affects breathing at night) or other respiratory conditions) machine on her admission MDS. This failure placed Residents at risk of having inaccurate assesments to include those who need a bipap machine at night, that could lead to Residents careplan not being correct and Resident not recieving care as needed. The findings included: Record review of Resident # 26's EMR and face sheet dated 05/07/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: displaced bicondylar fracture of right tibia (the shinbone…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that the comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #26) of 32 residents reviewed for comprehensive care plans. The facility failed to reflect Resident #26 used a Bipap machine (bilevel positive airway pressure device or Type of respiratory support therapy that uses positive air pressure to help individuals breathe, especially individuals who have sleep apnea (a condition that affects breathing at night) or other respiratory conditions) machine and Resident #26's shortness of breath diagnosis was not reflected on her comprehensive care plan. This failure affects residents who need a bipap machine at night and could result in lack of oxygen to the brain. The findings included: Record review of Resident # 26's EMR and face sheet dated 05/07/2025 reflected she was admitted to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one Resident (Resident #294) of 4 Residents reviewed for pressure sore management. 1. LVN C failed to document an accurate skin assessment for Resident #294 on 05/08/2025. This failurecould place Resident at risk on not recieving appropriate care leading to worsening of skin condition. The findings included: 1. Record review of Resident #294's EMR, electronic face sheet dated 05/03/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: fracture of upper end of right humerus (break or crack in the bone located at the upper part of the arm near the shoulder joint), fracture of lower end of left radius (bone in forearm breaks near the wrist joint), chronic kidney disease (moderate decrease in kidney function),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 resident (Resident #293) of 32 residents reviewed for safe environments. The facility failed to ensure Resident #293 did not have flammable materials near her oxygen. This deficient practice places residents on oxygen therapy at risk for burns. The findings included: Record review of Resident #293's EMR, electronic face sheet dated 05/08/2025 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia and hemiparesis (neurological conditions resulting from stroke or other brain damage, affecting one side of body. Hemiplegia is complete paralysis, while hemiparesis is weakness or impaired movement.) following cerebral infarction, (a type of stroke where blood supply to the brain is disrupted) acute respiratory failure with hypoxia (a condition where the lungs fail to adequately transfer…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews 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 resident's goals and preferences for 1 resident (Resident #26) out of 3 residents observed for respiratory therapy. The facility failed to obtain physician orders for Resident #26's Bipap she used each night at the facility since her admission on [DATE]. This failure place residents who reside at the facility at risk for inaccurate care and communication of health conditions to other providers. The findings included: Record review of Resident # 26's EMR and face sheet dated 05/07/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: displaced bicondylar fracture of right tibia (the shinbone is broken in two parts affecting both the medial and lateral bumps and the fragments are out 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the residents were seen by a physician at least at least once every 60 days for 2 of 6 Residents (Resident #2 and Resident 92) whose records were reviewed for physician visits. 1. The facility failed to ensure Resident #2's primary care physician met with Resident #2 as required. 2. The facility failed to ensure Resident #92's primary care physician met with Resident #92 as required. This deficient practice could affect any resident and could contribute to the resident's medical needs not being addressed or met. The findings were: 1. Review of Resident #2's face sheet, dated 5/9/25, revealed he was admitted to the facility on [DATE] with diagnoses including Epilepsy and personal history of Traumatic Brain Injury. Review of Resident #2's quarterly MDS assessment, dated 4/14/25, revealed his BIMS was 11 of 15 reflective of moderate cognitive impairment. Review of Resident #2's electronic health record including physician progress notes from…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record reviews, the facility failed to provide pharmaceutical services to administer drugs and biologicals that meet the needs of each resident for 2 of 5 medication carts (Cart #1 and #2 on 800 hall) observed and for 1 of 2 medication rooms ([NAME] Hall) observed. 1.The facility failed to remove expired medications from medication cart #1 and medication cart #2 on the 800 hall. 2. The facility failed to remove expired medication from the medication room on the [NAME] hall. These failures could place residents at risk of decreased therapeutic response and illness from expired medications. The findings included: Observation of the medication rooms on 5/7/2025 at 9:45AM revealed the [NAME] Unit medication room had an open box of Preparation H with a label expiration date of 5/2024. Observation of medication carts on 5/7/2025 at 10:00AM revealed medication carts #1 had 5 over the counter medications that were opened and were used. Record review of the 5 labels revealed the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-05-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 (Residents #26 and #293) of 32 residents observed for medication safety and security. 1. The facility failed to store Resident #26's Flonase (allergy nasal spray) in the medication cart and the medication was left on Resident #26's bedside table. 2. The facility failed to store Resident #293's Flonase (allergy nasal spray) in the medication cart and the medication was left on Resident #293's bedside table. These failures could result in , access to medications by unauthorized persons, and could result in decreased health response or misuse of medication. The findings included: 1. Record review of Resident # 26's EMR and face sheet dated 05/07/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: displaced bicondylar fracture of right tibia (the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #294) of 32 residents reviewed for EBP. The facility failed to establish EBP for Resident #294 when she had an open sacral wound with a dressing. This facility failure affects residents with open wounds, or other requirements for EBP, and could result in MDRO contamination. The findings included: Record review of Resident #294's EMR, electronic face sheet dated 05/03/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: fracture of upper end of right humerus (break or crack in the bone located at the upper part of the arm near the shoulder joint), fracture of lower end of left radius (bone in forearm breaks near the wrist joint), chronic kidney disease (moderate…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 medical records on each resident that were complete and accurately documented for 2 of 15 residents (Residents #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure Resident #1's physician's orders dated 02/27/25 were updated to include the resident no longer received wound treatment to a stage 2 wound to her sacrum (triangular bone on the lower back) to include LVN A signing off for completing these treatments from March 17th to the 19th 2025. 2. The facility failed to ensure Resident #2's physician's orders dated 01/24/25 were updated to include the resident no longer received wound treatment to DTI area to his left heel to include LVN A signing off for completing these treatments from March 17th to the 19th 2025. These deficient practices could place residents at risk of improper care due to inaccurate medical records. The findings included: 1. Record review of Resident #1's face sheet, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-25 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Residents #1) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #1's eMAR reflected when she received oxycodone as follows: 10/14 at 12:00 PM, 10/15 08:00 AM, 10/17 12:07 AM, 10/20 03:00 AM, 10/21 at 11:25 AM, 10/22 10:45 AM, 10/23 01:50 PM, 10/23 05:00 PM, 10/26 04:21 AM, 10/27 06:10 PM, 10/29 08:00 PM, 10/30 07:30PM, 10/31 04:30 PM, 11/01 04:30 PM, 11/03/24 01:58 AM, 11/04 08:00 PM, 11/5 08:00 PM, 11/8 08:00 PM, 11/11 08:00 PM, 11/12 08:00 PM, 11/14 08:00 PM, 11/14 (time illegible), and 11/19 12:15 AM, resulting in the missed requirement to assess the effectiveness of this medication. This deficient practice could put residents at risk for pain and anxiety. Findings include: 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record reviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety for 1of 2 (Willow Unit) nutrition rooms reviewed for storage: 1. The refrigerator on [NAME] Unit had a red sticky substance from spilled liquids on the shelves, on the door, and on the bottom shelf where nutritional supplements were stored for the residents. 2. The freezer on [NAME] Unit had food particles and stains from spilled liquids which had dried, a strand of hair on the floor of the freezer compartment where there were packages of food stored. 3. The ice machine on [NAME] Unit had a large amount of white hard water stains that had come from the vent of the ice maching and a black residue on the inside above the ice on the outlet where ice is dispensed into the unit. These failures could place 12 of 45 residents who receive snacks from the nutrition room at risk for food borne illness and contamination of food by airborne particles Findings included: During observation on 04/02/24 11:00 AM of 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet a resident's medical and nursing needs including the services to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 of 8 Residents (Resident #67) whose records were reviewed for care plans. Nursing staff failed to care plan Resident #67's skin conditions including autoimmune disease (Conditions where the immune system mistakenly attacks healthy body cells)-induced wound to left forearm, autoimmune disease-induced wound to left leg and autoimmune disease-induced wound to left forearm. This deficient practice could affect any resident and contribute to residents not receiving care and services as needed for skin conditions. The findings were: Review of Resident #67's quarterly MDS assessment, dated 2/26/23, revealed she was admitted to the facility on [DATE] with diagnoses…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 of 1 Resident observed for mechanical lift transfer. CNA I failed to apply the brakes and widened the legs on the mechanical lift when raising Resident #8 into the air and transferring him from the bed to the wheelchair. CNA I also turned the mechanical lift towards the motorized wheelchair by pulling on the sling because there was not enough space for her to maneuver the lift around the foot of the bed and in between the metal shelving unit in front of the foot board. These deficient practices could affect residents who used a mechanical lift for transfers, could cause avoidable falls and residents could sustain serious injuries from a fall from a mechanical lift. The findings were: Review of Resident #8's quarterly MDS assessment, dated 3/22/24, revealed he was admitted to the facility on [DATE] with diagnoses including seizure (a sudden, uncontrolled burst 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-05 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the bed's dimensions are appropriate for the resident's size and weight for 1 of 8 Residents (Resident 8) whose records were reviewed for the use of side rails. The facility failed to ensure the size of the mattress was compatible with the bed frame resulting in a significant gap between the mattress and the side rails. This deficient practice could affect any resident using a side rail and could result in avoidable injury to the resident. The findings were: Review of Resident #8's quarterly MDS assessment, dated 3/22/24, revealed he was admitted to the facility on [DATE] with diagnoses including seizure (a sudden, uncontrolled burst of electrical activity in the brain) disorder, Schizophrenia (is a serious mental disorder in which people interpret reality abnormally), Congenital myopathies (any genetic muscle disorder that is typically noticed at birth and includes weakness and lack of muscle tone), Generalized idiopathic epilepsy…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents for 1 of 8 Residents (Resident #1) whose records were reviewed for abuse. The ADM failed to report an allegation of resident abuse within 2 hours after learning about the allegation per facility policy. This deficient practice could affect any resident and contribute to further resident abuse. The findings were: Review of Resident #1' face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of Encounter for orthopedic aftercare following surgical amputation. Review of Resident #1's EHR revealed an initial MDS assessment was not completed. Review of Provider Investigation Report dated 3/19/24 revealed on 3/13/24 at 12 PM LVN A overheard Resident #1 making an allegation of resident abuse about CNA C. Further review revealed the allegation was reported to HHSC on 3/13/24 at 6 PM. Review of LVN A's statement of events dated 3/13/24 read:…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse for 1 of 8 Residents (Resident #1) whose records were reviewed for abuse. The ADM failed to report an allegation of resident abuse within 2 hours after learning about the allegation per facility policy. This deficient practice could affect any resident and contribute to resident abuse. The findings were: Review of facility policy Abuse Prohibition Protocol, dated April 2019 read: 2. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation of patient property and exploitation (collectively Patient Abuse) by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient, family members, legal guardians, friends, or other individuals. 10. The Abuse Prevention Coordinator will: 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-15 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 Assessment for 1 of 4 (Resident #22) residents for MDS review. The facility failed to do a Comprehensive Assessment upon admission for Resident #22 who was admitted to the facility for respite while on hospice. This deficient practice could contribute to the resident not receiving the care and services needed. The finding were: Record review of Resident #22's face sheet dated 3/14/2024 revealed she was admitted [DATE] for respite for five days with a discharge date of 9/5/2023. The resident had diagnoses that included: Parkinson's disease, Rhabdomyolysis, ( the breakdown of muscle tissue that releases a protein called myoglobin that can cause kidney damage) dementia with anxiety, and hypotension (low blood pressure). Record review of Resident #22's electronic medical record revealed the resident did not have a Comprehensive Assessment upon admission to the facility for respite. During an interview on 3/14/2024 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-17 · tag F0849 — pattern
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure 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 3 of 6 residents (Resident #55, Resident #53, and Resident #22) reviewed for hospice services, in that: 1. Facility did not ensure Resident #55's Certification of Terminal Illness form was in the resident's records 2. Resident #53's Hospice Election form was completed incorrectly, the Certification of Terminal Illness form was missing, and the Hospice Plan of Care had expired. 3. Facility did not ensure Resident #22's hospice election form was in the resident's records This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the rights to reside and receive services in the facility with reasonable accommodation of resident needs and preferencesfor 2 of 28 residents (Resident #47 and Resident #50) reviewed for resident rights, in that: Facility did not ensure the automated handicap push button, at the front lobby, to exit the facility allowed residents to easily exit the facility, while in a wheelchair. This deficient practice could place residents at risk for bodily injury while attempting to leave the facility by pushing the automated handicap button. The findings were: Record review of Resident #47's face sheet, dated 02/17/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: spinal stenosis, anxiety, asthma, shortness of breath, and recurrent depressive disorder. Record review of Resident #47's quarterly MDS, dated [DATE], revealed the resident had a BIMS of 10, which indicated the resident was moderate…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-17 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program, and failed to refer all residents with possible serious mental disorder for level II resident review for 1 (Resident #30) of 26 residents reviewed for PASARR program, in that: Resident #30 had a serious mental disorder and was not referred for level II review. This failure could result in residents with serious mental disorders not receiving support services. The findings were: Record review of Resident #30's face sheet, dated 02/17/2023, revealed the resident was admitted on [DATE] with diagnoses including: schizoaffective disorder bipolar type, generalized anxiety disorder, and pain unspecified. Record review of Resident #30's comprehensive MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. [Resident #30] ineffective individual coping [related to] inability to manage internal and external stressors secondary to anxiety,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CANTEX CONTINUING CARE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.1+1.9 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 3 of 51.9+1.1 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 36 homes this chain runs (chain average 3.1★, per CMS)
1 of 5The Carlyle at Stonebridge ParkSouthlake, TX 1 of 5The Colonnades at Reflection BayPearland, TX 1 of 5The CrescentSugar Land, TX 2 of 5Ashford GardensHouston, TX 2 of 5Magnolia ManorGroves, TX 2 of 5Palomino PlaceMesquite, TX 2 of 5Park Valley Inn Health CenterRound Rock, TX 2 of 5San RemoRichardson, TX 2 of 5SorrentoSan Antonio, TX 2 of 5Sundance Inn Health CenterNew Braunfels, TX 2 of 5The Villa At Mountain ViewDallas, TX 2 of 5Windemere At Westover HillsSan Antonio, TX 2 of 5Windsor GardensLancaster, TX 3 of 5Bel Air at TeravistaRound Rock, TX 3 of 5Fort Bend Healthcare CenterRosenberg, TX 3 of 5HollymeadFlower Mound, TX 3 of 5LarkspurLufkin, TX 3 of 5Mill CreekSilsbee, TX 3 of 5Prairie EstatesFrisco, TX 3 of 5Renaissance Care CenterGainesville, TX 3 of 5Solera at West HoustonHouston, TX 3 of 5The Bradford At BrooksideLivingston, TX 3 of 5The Broadmoor at Creekside ParkThe Woodlands, TX 3 of 5The Harrison at HeritageFort Worth, TX 3 of 5The Manor at SeagovilleSeagoville, TX 4 of 5Beacon HillDenison, TX 4 of 5CarraraPlano, TX 4 of 5Oakwood Manor Nursing HomeVidor, TX 4 of 5The Belmont At Twin CreeksAllen, TX 4 of 5The Madison on MarshCarrollton, TX 4 of 5Woodville Health And Rehabilitation CenterWoodville, TX 5 of 5Bonne ViePort Arthur, TX 5 of 5Crestview CourtCedar Hill, TX 5 of 5Laurel CourtAlvin, TX 5 of 5Palma RealMathis, TX 5 of 5Riverside OaksVictoria, TX

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

Who owns this facility

Owner / managerTypeRoleSince
HOOPER, GRADYIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 12/01/2015
CORONADO CONTINUING CARE CENTER LTD COOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
MILLER, PATIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/27/2021
BISCH, ANNEIndividualADP OF THE SNFsince 03/14/2022
MANSOOR, SAADIndividualADP OF THE SNFsince 01/18/2022

CMS files one row per role, so the 8 rows in the source record cover these 5 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.

$6.4M
Net patient revenuemost recent cost report
-0.9%
Operating marginrevenue minus expenses
$1
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 27%Other / private 23%

This home reported $1 paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$312per resident / day
operating cost
$9,488per month
≈ monthly operating cost
$309per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676353. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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