William R Courtney Texas State Veterans Home

Location & what’s nearby

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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

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.

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.

Met the expected recovery: 31.8% 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 22 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.

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.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. Inspectors cited this home for failing to submit its staffing data to CMS (F0851) — see the citation below; CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

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.

28 citations, most serious first. The 15 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-07-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 (Residents #1 and #2) of 12 residents reviewed for resident to resident altercations. The facility failed to prevent Resident #2 from being abused when Resident #1 punched him and knocked him on the floor, resulting in pain. Staff failed to notify the ADM, who was the abuse coordinator of the incident. This failure resulted in an IJ being identified on 07/22/25. The IJ template was provided to the facility on [DATE] at 6:05 p.m. While the IJ was removed on 07/23/25, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of abuse, neglect, change in condition, and…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-07-23 · 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 observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for two out of eight residents (Resident #1 and Resident #2). 1.The facility staff did not report Resident #1 and Resident #2's resident-to-resident altercation to the administrator immediately after the incident on 05/27/25. 2. The facility failed to report to Health and Human Services alleged abuse that occurred in the facility's secured unit on 05/27/25 involving Resident #1 and Resident #2. This failure resulted in the identification of Immediate Jeopardy (IJ) on 07/02/25 at 5:00pm. While the immediacy was removed on 07/03/25 at 12:58pm the facility remained out of compliance at scope of isolated and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of ongoing abuse, neglect, pain,…

  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
• Immediate jeopardy · Jcited before2025-07-23 · 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 observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for two out of eight residents (Resident #1 and Resident #2) 1.The facility staff did not report Resident #1 and Resident #2's resident-to-resident altercation to the administrator immediately after the incident on 05/27/25. 2. The facility failed to report to Health and Human Services alleged abuse that occurred in the facility's secured unit on 05/27/25 involving Resident #1 and Resident #2. This failure resulted in the identification of Immediate Jeopardy (IJ) on 07/02/25 at 5:00pm. While the immediacy was removed on 07/03/25 at 12:58pm the facility remained out of compliance at scope of isolated and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of ongoing abuse, neglect, pain,…

  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
• Immediate jeopardy · J2025-03-22 · 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 interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for elopement. 1. The facility failed to ensure Resident #1's wander guard bracelet was secured on his wrist so he could not remove it before he eloped from the facility on 03/15/25. 2. The facility failed to ensure staff noticed Resident #1 was missing until approximately 11 hours after he left the faciity on [DATE]. An IJ was identified on 03/21/25. The IJ template was provided to the facility on [DATE] at 4:57 p.m. While the IJ was removed on 03/22/25, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving adequate supervision, injury, and death. Findings included: Review of Resident #1's admission…

  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
• Immediate jeopardy · Kcited before2024-01-12 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 9 (Resident #11, Resident #51, Resident #54, Resident #62, Resident #77, Residents #105, Resident #116, Resident #135, and Resident #137) out of 148 residents reviewed for infection control. The facility failed to: 1. Isolate a resident with confirmed scabies (Resident #105) and five other residents (Residents #11, #51, #54, #62, #116, and #137) presented with rashes. On 01/10/24 at7:20 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/12/24 at 9:27 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. 2. Ensure CMA M administered Resident #135's eye…

  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 before2026-06-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one resident (Resident #1) out of 11 residents reviewed for abuse and neglect in that:CNA B observed CNA A tapping Resident # 1's mouth, several times, during care, while she was when she went to ask CNA A if she needed assistance with getting Resident #1 to bed on 05/21/2026.This failure could place residents at risk of physical and mental or emotional harm, fear, and anxiety. Findings included:Record review of Resident #1's admission recorded dated 06/15/2026 documented an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses included: Alzheimer's Disease(progressive, irreversible brain disorder that slowly destroys memory and thinking skills), dementia(decline in mental ability-such as memory, thinking, and reasoning severe enough to interfere with daily life), and chronic kidney disease(long-term condition where the kidneys are damaged and lose their ability to properly filter waste and excess fluid 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-05-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure DA H wore a hair net when standing over the food prep table and portioning salads on plates. The facility failed to ensure DA H washed her hands between food preparation tasks.The facility failed to ensure the [NAME] used proper hand sanitation between puree preparation.The facility failed to and LVN A used proper hand sanitation during food plate distribution for the lunch meal.The facility failed to ensure CNA C and LVN B used proper hand sanitation during food plate distribution for breakfast meal.The facility failed to ensure that designated hand-washing station 2 had hand soap, paper towels, or designated trash bin available for staff to use between kitchen tasks. These failures could place residents at risk of foodborne illness and food contamination.Findings included:During an observation on 05/19/2026 at 8:56 am…

  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 · F2026-05-21 · tag F0851 — widespread
  Electronically 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 electronically submit to CMS complete and accurate direct care staffing information for the first quarter (October 1, 2025, to December 31, 2025). The facility failed to submit complete PBJ staffing information to CMS for October 1, 2025, to December 31, 2025. This failure could place all 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: Record review of the CASPER3 PBJ report reflected the facility failed to submit data for the FY quarter 1 (October 1, 2025- December 31, 2025). No other quarter was triggered. An interview was conducted on 05/21/2026 at 3:35PM with the DON, who reported that she was not aware that quarter 1 PBJ was not submitted. The DON stated that she was responsible for reporting the data and stated the failure was an oversight. An interview was conducted on 05/21/2026 at 4:54PM with the ADM, who reported that the PBJ staffing data was not…

  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 · E2026-05-21 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received and were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 residents (Residents # 51 # 65 and #135) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Residents #51, #65 and #135. The facility failed to provide palatable food served at an appetizing temperature and taste for 3 test trays provided to the survey team. This failure could place residents at risk of weight loss, altered nutritional, status, and diminished quality of life. Findings include: Record review of Resident #51's admission Record dated 05/21/2026 revealed an [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #51 had a diagnosis which included Alzheimer's Disease with late onset, (A type of brain disorder that causes problems with memory, thinking, and behavior. This is gradually progressive…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-21 · 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 ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 3 residents (Resident # 68) reviewed for PASARR Level I screenings. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #68. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis major depressive disorder and bipolar disorder was present upon admission. The facility did not complete a 1012 form to update Resident #68 PASARR Level 1 with the diagnosis. These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.Findings included: Record review of Resident #68's undated face sheet reflected an [AGE] year-old male who admitted to the facility on [DATE]. Resident #68 had diagnoses of Neurocognitive disorder with…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-01 · 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 Abbreviations: Based on interview and record review, the facility failed to immediately notify the resident's representative when the resident experienced a change in condition for 1 of 3 residents (Resident #1) reviewed for a change of condition. The facility failed to notify Resident #1's Responsible Party (RP) when she was put on contact isolation precautions for E coli. This failure could place residents at risk delayed coordination when they experience a change in condition. Findings include: Record review of Resident #1's face sheet, dated 05/01/2026, reflected [AGE] year-old female admitted on [DATE] with diagnosis of personal history of urinary tract infection (a bacterial infection affecting the bladder, urethra, or kidneys). Record review of Resident #1's quarterly MDS assessment, dated 04/04/2026, reflected BIMS level of 15, intact cognition, and always incontinent for bladder and bowel (no episodes of continent voiding) Record review of Resident #1's nursing note, dated 04.18.2026, revealed 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 · D2026-02-23 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 15 (Resident #1) residents reviewed for care plan revisions.The facility failed to revise Resident #1's care plan to reflect interventions for physical aggression r/t anger due to dementia on 02//15/2026.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings included:Record review of Resident #1's admission record, dated 02/23/2026, revealed an [AGE] year-old male was admitted on [DATE]. Resident #1 had diagnoses which included: vascular dementia (progressive decline in thinking and memory skills caused by reduced blood flow to the brain), Alzheimer's disease (memory loss, cognitive decline, and behavioral changes due to brain cell death), and major depressive disorders (sad).Record review of Resident #1's Quarterly MDS assessment, dated 02/18/2026, revealed the resident had a BIMS score that was…

  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 · E2026-02-04 · tag F0755 — failed to provide safe pharmacy services — pattern
  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 which includes the accurate acquiring and administering of medications to meet the needs for 1 (Resident #1) of 5 residents reviewed for pharmacy services, in that:The facility failed to administer Resident #1's Lorazepam medication according to physicians' orders on 12/16/2025, 12/17/2025, and 12/18/2025 resulting in Resident #1 getting double the amount of his scheduled medication.This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.Review of Resident #1's face sheet dated 2/3/2026 reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included vascular dementia (decline in cognitive function caused by impaired blood flow to the brain), Alzheimer's disease (progressive neurological brain disorder leading to cognitive decline), type 2…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-25 · 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

  Based on observation and interview, the facility failed to ensure all drugs and biologicals were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 of 2 medication carts (Med Cart #1) reviewed for medication storage in that: The facility failed to prevent Med Cart #1 from being unattended and unlocked against the wall across from the nurses' station on the 300/400 Hall on 6/24/2025. This failure could allow residents, visitors, staff, and unauthorized individuals unsupervised access to prescription and over-the-counter medications. Findings Include: Observation on 6/24/2025 at 4:10 am revealed, Med Cart #1 sitting against the wall across from the nurses' station on the 300/400 Hall was unsupervised and unlocked. A review of the contents of Med Cart #1 revealed prescription and over-the counter medications and ointments, glucometer supplies, insulin pens, and insulin syringes. MA-A was not in visible sight and there were no staff in the nurses' station. Multiple staff members were escorting residents to the dining room for dinner and walked…

  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 · E2025-03-22 · 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 interviews and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 12 residents reviewed for elopement. The facility failed to ensure staff's statements were accurately documented when they last observed and checked on Resident #1 before he eloped on 03/15/25. This failure could place residents at risk of not being checked on, eloping, falls, and changes in condition. Findings included: Review of Resident #1's admission Record, dated 03/21/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, unspecified dementia, depression, and unsteadiness on feet. Resident #1 had an MPOA and FPOA, which were his responsible parties. Review of Resident #1's admission and Modified MDS Assessments, dated 12/25/24, reflected he had a BIMS score of 12, which indicated he had moderate cognitive impairment.…

  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.

Fines & penalties

$53,860 in federal fines across 3 penalties.

• $15,755 — penalty dated 2025-06-25
• $10,922 — penalty dated 2025-03-07
• $27,183 — penalty dated 2024-01-12

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to TEXVET — 9 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 →

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

The source lists no ownership percentage for any party here — 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.

What families pay in TX