Schulenburg Regency Nursing Center
111 College St, Schulenburg, TX 78956 · For profit - Corporation · 146 certified beds · (979) 249-6537 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2024
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,827 in federal fines (most recent 2024-12-13)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 31.1% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.4% | 3.0% | 5.4% | worse |
| 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 | 1.8% | 0.8% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.0% | 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 | 4.8% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.8% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.3% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.7% | 13.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.8% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.9% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.6% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 40.9% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.9% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.73 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.11 | 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.
44.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 109 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.5% 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 76 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 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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 | 44.3%CMS range 35.0–52.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.5–14.6 | 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 | 60.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 52.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 11.5%CMS range 7.7–16.4 | 7.1% | Oct 2023–Sep 2024 | worse than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.49 | 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 146 beds and averages 109.3 residents a day — about 75% occupied, or roughly 37 beds typically open. It usually has some room. 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.19 hrs/resident/day on weekends vs 3.92 on weekdays — 19% thinner on weekends. RN hours go from 0.34 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · J2024-12-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #109) of 4 residents reviewed for elopement on 10/27/24. The facility failed to put interventions in place to prevent Resident #109 from eloping from the facility when she walked out of the memory care unit and exited the fire alarm gate on 10/27/24. Resident #109 was found by an exit door again on 12/01/24 . Resident has history of opening the doors after pushing on them for 15 seconds allowing the door to open. An IJ was identified on 12/12/24. The IJ template was provided to the facility on [DATE] at 3:30 PM. While the IJ was removed on 12/13/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need 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.
- Potential for harm · Ecited before2026-03-11 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure 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.The facility failed to ensure that the medications stored in the medication storage room [ROOM NUMBER] were not expired.This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.The findings included:During an observation in medication room [ROOM NUMBER] on 3/9/2026 at 10:30am it was revealed that the following medications and other items were expired:Two bottles of Pro - Stat Concentrated Liquid Protein 30 fluid ounces. The date of expiry printed on it was January 21, 2026. One Miconazole Nitrate Vaginal Cream 4% vaginal antifungal with 2 applications in the box. The expiry date printed on it was September 2025.Two dressing change kit with Stat…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 17, and Resident #92) reviewed for ADL care.The facility failed to ensure Resident #17's and Resident #91's nails were cleaned and did not have any rough edges.This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Record review of Resident #17's face sheet, dated 03/10/2026, reflected a [AGE] year-old male, admitted [DATE], with diagnoses: type 2 diabetes mellitus without complications ( a chronic metabolic disorder where the body develops insulin resistance and fails to use insulin properly without any complications), muscle weakness (a decrease in the ability to exert force with your muscles, meaning they do not contract or move as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents received care, consistent with professional standards of care to prevent development or promote wound healing for one ( Resident # 6 ) of 3 residents reviewed for pressure ulcers. The facility failed to perform Resident #6's thorough skin assessments on Sunday 03/08/2026 new skin issues to right gluteus (buttock), rear left thigh, and right fourth toe. These failures could place residents at risk for worsening skin concerns leading to discomfort, pain, and potential infections. Findings included:Record review of Resident #6's face sheet, dated 3/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE], diagnoses included type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic- hyperosmolar coma (extremely high blood sugar (> 600 mg/dL), severe dehydration, and high blood concentration without significant ketone- chemicals produced by the liver from fat…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of two kitchens reviewed for kitchen sanitation. The facility failed to ensure Dietary Assistant [NAME] D used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: Observation and interview on 03/09/2026 at 12:15 p.m. revealed Dietary Assistant [NAME] D was holding the top of a clip board with both of her bare hands. There was a hard black substance covering the top of the clip board where Dietary Assistant [NAME] D had her fingers on her right and left hand touching the substance. Dietary Assistant [NAME] D placed the clip board on top of a shelf and she touched the right side of her scrub top with fingers on her right and left hand. Dietary Assistant [NAME] D walked to the steam table and picked up a divided plate with her left hand. Her fingers on her left hand were located inside the plate,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #21 and Resident #87) of four residents reviewed for infection control practices, in that: The facility failed to ensure Med Aide C sanitized the blood pressure monitor before Resident #21, in between Resident #21 and Resident #87 and after Resident # 87 while obtaining blood pressure.This failure could place residents at risk for healthcare associated with cross-contamination and infections.Findings included:Review of Resident #21's face sheet dated 03/09/26 reflected an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses including unsteadiness on feet, muscle weakness, muscle wasting, lack of coordination , history of falling, and hypertension (high…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of two kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Assistant [NAME] A used proper hand hygiene during food preparation.2. The facility failed to ensure Dietary Assistant [NAME] A used appropriate oven mitt to remove food from the oven and prevent cross-contamination of the food. These failures could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: 1. Observation on 11/01/2025 at 7:20 AM, reflected Dietary Assistant [NAME] A touched her shirt, the right side of her hair, and touched her face with her right hand. She did not wash or sanitize her hands prior to touching the cereal in bowls on a meal tray. She placed the meal tray full of bowls of cereal in the meal cart to be delivered to the 600-hall kitchenette. Interview on 11/01/2025 at 7:30 AM, Dietary Assistant [NAME] A stated she did not wash her hands, and she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-13 · tag F0657 — failed to keep the care plan current — patternDevelop 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 interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, which included measurable objectives and time frames to meet the resident's mental and psychosocial needs for 3 of 10 residents (Residents #17, #41 and #98) reviewed for care plans. 1. The facility failed to update Resident #17's care plan to reflect current needs for suprapubic catheter care. 2. The facility failed to update Resident #17's care plan to reflect current needs with transfers. 3. The facility failed to update Resident #41's care plan to reflect current diet consistency orders. 4. The facility failed to update Resident #98's care plan to reflect current needs with transfers. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings included: Record Review of Resident #17's admission record dated 12/11/24 revealed an [AGE] year-old male admitted on [DATE]. Resident #17's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-13 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the residents rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 5 residents (Resident #26) reviewed for advanced directives. The facility failed to ensure Resident #26's out of hospital do-not-resuscitate (OOH-DNR) order form was signed by a physician. These failures could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention due to confusion. Finding included: Review of Resident #26 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, altered mental status, cognitive communication deficit, hypertensive heart disease with heart failure, and unspecified diastolic (congestive) heart failure. Review of Resident #26 physician orders dated [DATE] reflected an order for do not resuscitate. Review of Resident #26 care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-13 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents had the right to be free from resident neglect for one (Resident #12) out of three residents reviewed for neglect. The facility failed to ensure FTA from ensuring the facility lift was located at the back facility door to transfer Resident #12 off the van onto the lift . Resident #12 fell from the van onto the lift located on the ground on 11/15/2024. This noncompliance was identified as PNC. The deficient practice occurred on 11/15/2024 and in-service was completed on 11/15/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of neglect, injury, and psychosocial harm. Findings included: Record review of Resident # 12's face sheet, dated, 12/11/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12 had diagnoses which included vascular dementia ( a condition that affects the brain's ability to think,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-13 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 right to be free from misappropriation of property for 1 of 5 residents (Resident #38) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #38's Hydrocodone-Acetaminophen, a medication to help with pain. This failure could place residents at risk for not receiving prescribed medications. Findings included: Record review of Resident #38's admission record dated 12/12/24, reflected the resident was admitted [DATE]. Her diagnoses included dysphagia (difficulty swallowing), cerebral infarction (stroke), Rheumatoid arthritis (the immune system attacks the body's tissues, leading to swelling and joint deformity and pain), and pain. Record review of Resident #38's quarterly MDS dated [DATE] reflected a BIMs score of 0 indicating severe cognitive impairment. Record review of Resident #38's physician orders dated 11/3/24 reflected an active order for Hydrocodone-Acetaminophen 5-325mg 1 tablet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · Dcited before2024-12-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication storage rooms reviewed for medications. The facility failed to remove 2 expired suppositories and 1 bag of expired medication from the medication storage room when it was observed on 12/11/24 at 12:50 PM. This failure could place residents at an increased risk of receiving expired and/or contaminated medications which could result in adverse health consequences. Findings included: Observation on 12/11/24 at 12:50 PM in the medication storage room revealed 2 suppositories of bisacodyl 10 mg with expiration date 09/24 and one bag of Gentamicin 60 mg in 100 ml 0.9% sodium chloride for intravenous use with expiration date 12/6/24, belonging to Resident #36. Review of Resident #36's admission record dated 12/12/24 revealed an…
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 before2024-12-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 3 of 12 residents (Resident #9, Resident #25 , Resident #102, ) observed for infection control. 1. The facility failed to ensure all staff donned PPE when entering rooms of residents' rooms who were on droplet precautions. 2. The facility failed to ensure PPE was adequately stocked for residents on droplet precautions. These failures could place residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #9 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia (a decline in mental ability that affects memory, thinking, and behavior), heart failure, and chronic fatigue (a long-term illness that causes severe fatigue and makes it difficult 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.
- Potential for harm · E2024-11-14 · tag F0839 — patternEmploy staff that are licensed, certified, or registered in accordance with state laws.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 8 (Residents #1, #2, #3, #4, #5, #6, #7, and #8) of 9 residents reviewed for assessments. The facility failed to ensure the ADON had a current and active license. The ADON provided assessments to Residents #1, #2, #3, #4, #5, #6, #7, and #8 while her RN license was expired from [DATE] through [DATE]. This could place residents at risk for inadequate care and/or services. Findings included: Review of Resident #1's admission record, dated [DATE], reflected an [AGE] year old female who was admitted to the facility on [DATE], discharged on [DATE], and had diagnoses including malignant neoplasm of bilateral ovaries (a cancerous tumor in both ovaries), unspecified anxiety disorder, restlessness and agitation, age-related osteoporosis without current pathological fracture (a condition that occurs when bones become less dense and more likely 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.
- Potential for harm · F2023-10-26 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information (Quarter 3 2023). The facility failed to submit PBJ staffing information to CMS for the 3rd quarter (April 1 - June 30) of fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the facility's undated Civil Rights Survey Report (Form 3761) indicated the following: 7 RNs 24 LVNs 42 Direct Care Staff 14 Dietary 22 Housekeeping & Laundry 12 All Others Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheter care (Resident #6 and Resident #30). A) The facility failed to ensure Resident #6's catheter was secured to her body with a catheter secure device per the care plan and physician's orders. B) The facility failed to ensure Resident 30's catheter was secured to his body with a catheter secure device per the care plan and physician's orders. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings included: Review of Resident #6's Face Sheet dated 10/26/2023 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses Extended Spectrum Beta Lactamase (ESBL) (A type of enzyme or chemical produced by some bacteria that can break down the active…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,827 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $8,827 — penalty dated 2024-12-13
- Medicare payment denial — starting 2025-01-15 for 1 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OAK MANOR, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 03/02/2026 |
| CLG FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 01/01/2025 |
| GREIVE, CHARLES | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNF | — | NO DATE PROVIDED |
| HATFIELD, PEYTON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/13/2024 |
| KLAUS, BART | Individual | ADP OF THE SNF | — | since 05/01/2024 |
| PASCHALL, KRISSI | Individual | ADP OF THE SNF | — | since 03/31/2021 |
CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $579K 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 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 455908. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, 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.