No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Oakwood Manor Nursing Home

225 S Main St, Vidor, TX 77662 · For profit - Corporation · 100 certified beds · (409) 769-5697 Medicare & Medicaid certified

Call the home — (409) 769-5697 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Mar 2026
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1091 N Main St · (409) 769-0237 · Call to confirm hours
Pharmacy
315 N Main St · (409) 769-2438 · Call to confirm hours
Grocery
1079 Orange St · (409) 769-4950 · Call to confirm hours
Park
195 W Bolivar St · (409) 673-7441 · Typically dawn to dusk
Place of worship

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 4 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 increased2.0%15.8%15.4%better
Long-stay residents who lose too much weight2.3%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 injury1.8%3.3%3.3%better
Long-stay residents whose ability to walk worsened1.9%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.1%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers3.5%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control6.8%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table1.2%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.2%88.0%79.4%better
Short-stay residents rehospitalized after admission32.5%25.7%22.6%worse
Short-stay residents with an outpatient ER visit9.3%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days2.482.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.592.061.80better

* 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.

61.1% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.1%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 54 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 SNF61.1%CMS range 51.6–69.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.3–15.810.7%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 discharge50.0%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 discharge57.4%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 discharge31.5%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 identified90.8%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 setting96.8%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%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 worsened2.3%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 hospitalization6.5%CMS range 3.1–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.851.02Oct 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

0.22
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.06
Aide hours/ resident / day
3.23
Total nurse hours/ resident / day
0.20
RN hoursweekends
37.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 85.2 residents a day — about 85% occupied, or roughly 15 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 2.76 hrs/resident/day on weekends vs 3.42 on weekdays — 19% thinner on weekends. RN hours go from 0.23 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% 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

3
deficiencies at the latest standard inspection (2025-12-17)
6
at the previous standard inspection (2024-09-25)

Deficiencies are fewer than at the previous inspection — improving. 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.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Dcited before2026-03-31 · 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 interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of abuse. The facility failed to ensure MA A reported an allegation of abuse to the Abuse Coordinator immediately when Resident #1 told them on 3/12/26 that CNA B was rough during care The facility failed to ensure MA E and CNA B reported an allegation of abuse, made by Resident #1, to the Administrator immediately when they learned of the allegation on 03/18/26. MA E reported the allegation to CNA B 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
  • Potential for harm · Dcited before2026-01-15 · 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 observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for one of two resident's (Resident #1) reviewed for respiratory care. The facility failed to obtain physician orders for Resident #1's continuous oxygen. The facility failed to ensure Resident #1's nasal cannula was changed when it was touching the carpet on the floor, and it was placed back on Resident #1. These failures could place residents at risk for respiratory infections, an incorrect amount of oxygen, and the risk of lung infections.Findings included: Record review of Resident #1's face sheet, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure), dehydration, and right femur…

    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 · E2025-12-17 · 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 observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs for 1 of 4 halls (hall 300) reviewed for controlled medications and 1 of 19 residents rooms reviewed for unsecured medication, and 1 of 1 medication rooms reviewed for expired medications. The facility failed to ensure controlled medications were counted on 12/14/25 between the night and day shift for the 300 hall med cart. The facility failed to ensure controlled medications were counted on 12/15/25 between the day and night shift for the 300 hall med cart. The facility failed to ensure no loose pills were left on the floor of Resident #98's room. The facility failed to ensure the expired fast acting dairy relief lactase supplement (dairy relief) was not in the medication storage room from current supply. This failure could place residents at risk for medication overdose, medication under-dose,…

    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 · E2025-12-17 · tag F0761 — failed to label and store drugs safely — pattern
    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 observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 treatment cart and 1 of 1 medication storage rooms reviewed for storage of drugs and biologicals. The facility failed to ensure the treatment cart was locked and secured when the Wound Care Nurse left the treatment cart unlocked and unattended on [DATE] at 7:45 a.m. The facility failed to ensure the treatment cart #1 was locked and secured when the Wound Care Nurse left the treatment cart unlocked and unattended on [DATE] at 9:42 a.m. The facility failed to ensure Hall200's medication aides' medication cart was free of loose pills at the bottom of the medication cart on [DATE] at 12:00 p.m. The facility failed to ensure medication carts were free of loose pills at the bottom of the medication cart. These failures could place residents at risk of medication misuse or drug diversion. The findings included: 1. During 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-17 · 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

    Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection control 1 of 4 halls (hall 400) observed for infection control. The facility failed to ensure the Wound Care Nurse wore personal protective equipment (gown) while doing wound care. The facility failed to ensure the Wound Care Nurse performed hand hygiene between glove changes while doing wound care. The facility failed to ensure the Wound Care Nurse sanitized the wound cleanser bottle before putting it back in the treatment cart. These failures could place residents at risk of cross-contamination and development of infections.The findings included: During an observation on 12/14/2025 at 8:45 a.m. revealed the Wound Care Nurse began and ended Resident #74 (on enhanced barrier precautions for wound care.) wound care without personal protective equipment (gown) on. The Wound Care Nurse…

    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 before2024-09-25 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents reviewed for resident rights. (Resident #67) The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #67. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of a face sheet dated [DATE] indicated Resident #67 was an [AGE] year-old male admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), dementia (loss of cognitive functioning), and atrial fibrillation (a type of irregular heartbeat). Record review of an undated OOH-DNR indicated…

    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 · D2024-09-25 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a significant change MDS assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition a significant change of condition for 1 of 19 residents reviewed for assessments. (Resident # 53) The facility failed to complete a Significant Change MDS for Resident #53 within 14 days after the resident was admitted to hospice services. This failure could place residents who experienced a significant change in their condition requiring an MDS assessment at risk of not receiving needed services. Findings Included: Record review of a face sheet dated 09/24/24 indicated Resident #53 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic obstructive pulmonary disease (a lung disease that blocks airflow making 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-25 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 accurately submit a PL1 (PASRR Level 1 Screening) screening when a resident admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 1 of 6 residents reviewed for PASRR screenings. (Resident #333) The facility failed to submit a new PL1 screening when Resident #333 was diagnosed on [DATE] with Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily living) during his stay. This failure could place residents at risk of not receiving specialized services. Findings included: Record review of Resident #333's face sheet dated 09/24/24 was an [AGE] year-old-male admitted [DATE] with diagnoses of seizures (uncontrolled jerking, loss of consciousness and other symptoms caused by abnormal electrical activity in the brain), anxiety disorder (mental health disorder with feelings of worry, anxiety, or fear that are strong enough to interfere 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 · D2024-09-25 · 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 and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 19 residents reviewed for care plans. (Resident #6) The facility did not have a care plan to address Resident #6's Post Traumatic Stress Disorder (PTSD). This failure could place residents at risk of not having their individual needs met and not receiving needed services. Findings included: Record review of a face sheet dated 09/25/24 indicated Resident #6 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of an annual MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 14 indicating her cognition was intact and she had a diagnosis of PTSD. Record review of a care plan dated 07/25/19 to present indicated Resident #6 had no 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-25 · 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 that the resident environment remained free of accident hazards for 1 of 2 residents reviewed for smoking safety evaluations. The facility did not ensure the quarterly smoking evaluations were completed for Residents #59. This failure could place residents at risk of injury and contribute to avoidable accidents. Findings included: Record review of the face sheet dated 09/25/24 indicated Resident #59 was admitted on [DATE], was [AGE] years old with diagnoses of nicotine dependence, chronic obstructive pulmonary disease, diabetes and peripheral vascular disease (blood flow reduce to limbs). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #59 used tobacco. Record review of the care plan dated 09/25/24 indicated Resident #59 was a smoker and interventions included assist resident to smoking area and keep matches/lighters at the Nurses Station. Record review of the smoking evaluation form dated 01/30/24…

    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
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-09-25 · 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, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 2 of 7 residents (Resident #24 and Resident #27) reviewed for infection control procedures. The facility failed to ensure LVN B used enhanced barrier precautions (a set of infection control guidelines used to prevent spread of infections) while she administered medication to Resident #24 through a gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach). The facility failed to ensure LVN B used enhanced barrier precautions while she performed tracheostomy care (surgical opening into the neck for breathing) to Resident #27. These failures could place residents at risk for exposure to infections and communicable diseases. Findings included: 1. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-07-26 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to implement the ongoing system of surveillance to identify possible communicable diseases and infections before they can spread to other persons in the facility for 12 of 12 employees reviewed for annual tuberculosis (TB) screening. The facility required TB screening annually but did not have documentation of the annual TB screening done for the ADM, AD, ADON, BOM, DM, HS, MD, PT, ST, LVN D, LVN E, and CNA F. This failure could place residents, staff, and visitors at risk of being exposed of being exposed to a communicable disease and the facility not being aware of TB to report to the health department. Findings included: Record review of the facility Employee Tuberculosis Screening Nursing Policy and Procedure revised March 2019 indicated Policy: The Facility must screen all employees before providing services in the facility and annually, according to CDC guidelines. The facility must require all persons providing services under an outside resource contract to provide evidence of current tuberculosis screening prior 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-26 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 food was provided that accommodated food preference for 4 of 23 residents reviewed for food choices (Resident #7, #43, #66 and #75) in that: Residents #7, #43, #66, and #75 preferred fried eggs and did not receive fried eggs. This failure could place residents at risk for poor oral intake, weight loss, and poor quality of life. Findings included: 1. Record review of an admission face sheet for Resident #7 indicated she was admitted [DATE] with diagnoses of high blood pressure and pain. Record review of the physician orders dated July 2023 indicated Resident #7 had a diet order for Low concentrated sweet, no salt on tray and no fried foods. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7 had moderately impaired cognition with BIMS score of 12, could understand, and usually could make needs known. Record review of the care plan with print date of 07/26/23 indicated Resident #7 wanted to lose weight.…

    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 before2023-07-26 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 2 of 4 residents reviewed for advanced directives. (Residents #19 and #65) The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #19 and #65 This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of the Out-of-Hospital Do-Not-Resuscitate Order accessed on [DATE] at https://www.hhs.texas.gov/regulations/forms/advance-directives/out-hospital-do-not-resuscitate-ooh-dnr-order indicated on page 2: Instructions for Issuing An OOH-DNR Implementation: The OOH-DNR Order may be executed as follows: In addition, the OOH-DNR Order must be…

    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 · Dcited before2023-07-26 · 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

    Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 1 of 2 residents reviewed for reporting allegations of abuse. (Residents # 9 and #66) The facility did not report physical abuse within 2 hours when Resident #9 reported to facility staff that CNA B slapped her in the face. This failure could place the residents at risk of abuse and neglect. Findings include: Record review of clinical notes indicated on 6/28/2023 at 2:43 am resident ask to see nurse and she reported to LVN H that she did not want CNA B in her room anymore or to care from her anymore, said CNA had been rough with her when cleaning her, and she came in and slapped her in the face. Record review of an email to HHSC Complaint and Incident Intake dated 06/28/23 at 6:48 a.m. indicated the name and title of the person making the initial report; [ADM] 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-26 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 23 residents records reviewed for MDS assessments. (Residents #80) The facility did not ensure the discharge MDS assessment was completed and transmitted as required for Resident #80. This failure could place residents at risk of not having their assessments transmitted timely. Findings included: Record review Resident #80's admission record dated 07/26/23 indicated she was admitted on [DATE] with a discharge date of 02/24/23. Resident #80's diagnoses included shortness of breath, chronic obstructive pulmonary disease and lung cancer. Record review of the MDS for Resident #80 indicated the most recent MDS completed was on 02\02\23. There was not a discharge MDS completed or transmitted after 02/24/23. Record review of the nurse's notes 01/18/23 to 02/24/23 indicated Resident #80 was discharged home on [DATE]. During 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-26 · 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 observation, interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 3 of 23 residents reviewed for accuracy of assessments. (Resident #s 40, 42 and 71) The facility did not accurately complete the MDS assessment to indicate Residents #40 and #42 had dental concerns. The facility did not accurately complete the MDS assessment to indicate Resident #71 received continuous oxygen. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of physician orders dated 07/26/23 indicated Resident #40, admitted [DATE] was [AGE] years old with diagnoses of diabetes (a disease in which the body ability to produce insulin is impaired resulting in high levels of glucose in the blood), heart failure (a chronic condition in which the heart does not pump blood efficiently) and end stage renal disease (condition in…

    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 before2023-07-26 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 individuals identified with MD or ID are evaluated for 3 of 6 residents reviewed for PASRR. (Residents # 55, #73 and #89) The facility did not have an accurate PASRR level 1 screening for Residents #55, #73 and #89 who identified with having a mental health diagnosis therefore they had no further evaluation. This failure could place residents who have a diagnosis of mental disorder or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1. Record review of a face sheet indicated Resident #55 admitted [DATE], was a [AGE] year-old male, with diagnoses of PTSD (post-traumatic stress disorder -a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with symptoms including flashbacks, nightmares and severe anxiety), anxiety (intense, excessive, and persistent worry and fear…

    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 before2023-07-26 · 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 the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 23 residents (Resident #55) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for Resident #55 with the pruning shears and the shears were not stored securely. This failure could place residents at risk for injury due to the lack of supervision provided by the facility. Findings include: Record review of the face sheet for Resident #55 indicated he was admitted on [DATE], was [AGE] years old with diagnoses of PTSD (a disorder that develops in some people who have experienced shocking, scary or dangerous event), heart failure, high blood pressure and anxiety. Record review of physician orders dated July 2023 indicated Resident #55 had orders for morphine 15 mg immediate release tablet (1 1/2 tab) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-26 · 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, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 23 residents reviewed for oxygen therapy. (Resident #38 and Resident #71) The facility did not obtain orders for Resident #38's oxygen. The resident received oxygen via nasal cannula connected to a portable oxygen concentrator. The facility did not ensure humidifier bottles contained liquids for Resident #s 38 and 71. The humidifier bottles for each concentrator were empty. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: 1. Record review of the physician orders dated July 2023 indicated Resident #38, admitted [DATE], was [AGE] years old with diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or…

    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 · D2023-07-26 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for 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 residents obtained needed dental services, including routine dental services for 1 of 23 residents reviewed for dental services. (Resident #40) The facility did not obtain dental services for Resident #40, who had missing and decayed teeth. This failure could place the residents at risk for not receiving care and services to prevent further decline and weight loss. Findings included: Record review of physician orders dated July 2023 indicated Resident #40, admitted [DATE] was [AGE] years old with diagnoses of diabetes (a disease in which the body ability to produce insulin is impaired resulting in high levels of glucose in the blood), heart failure (a chronic condition in which the heart does not pump blood efficiently) and end stage renal disease (condition in which a person's kidneys cease to function on a permanent basis). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS assessment…

    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

“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 4 of 53.1+0.9 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 1 of 51.9-0.9 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 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 5Coronado At Stone OakSan Antonio, 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 / managerTypeRoleShareSince
TYLER COUNTY HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2017
WILLIAMS, SONDRAIndividualCORPORATE OFFICERsince 06/18/2007
OAKWOOD HEALTH CARE CENTER LTD. COOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
CZAJKA, ASHLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/16/2016
HAMMETT, CHADIndividualADP OF THE SNFsince 04/01/2022
SANTANA, SHAUNAIndividualADP OF THE SNFsince 02/03/2023

CMS files one row per role, so the 8 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.

$7.9M
Net patient revenuemost recent cost report
+4.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 61%Medicare 14%Other / private 25%

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

$254per resident / day
operating cost
$7,737per month
≈ monthly operating cost
$265per day
avg. revenue, all payers

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

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 675394. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-17, 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.

What to do next