Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
9E
1F
Potential for minimal harm
0A
0B
0C
June 29, 2026Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review, the facility failed to ensure that allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation is made to the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for injury unknown origin. The facility failed to report within 2 hours to the State Survey Agency (HHSC - Health and Human Services Commission) an injury of unknown origin when CNA A reported to LVN B that Resident #1 had complained of pain while trying to get out of bed on 05/29/2026 and was sent out to the hospital for further evaluation. Upon evaluation the hospital notified the facility that x-rays showed Resident # 1 had a distal femur fracture when the hospital reported to the facility on [DATE]. [...]
January 30, 2026Complaint inspection · 2 citations
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 (Resident #1) of 6 residents reviewed for nutrition status maintenance. The facility failed to Accurately and consistently assess a resident's weight status on admission and weekly for 4 weeks for Resident #1. These failures could place residents at risk of further weight loss, malnutrition, and a decreased quality of life.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a comprehensive care plan to meet the residents' highest practicable physical, mental, and psychosocial well-being of 1 (Resident #1) of 6 residents reviewed for care plans. The facility failed to update the comprehensive person-centered care plan for Resident #1's need for oral care and dentures. This failure could place residents at risk for not receiving appropriate care and treatment.
September 11, 2025Standard inspection · 10 citations
- J
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #101) of three residents reviewed for Dialysis Care. The facility failed to transport Resident #101 to her dialysis appointment on 09/05/2025 at 6:00am due to not having a driver. On 09/09/2025 at 4:45p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 9/11/2025, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the facility had sufficient staffing to meet the needs of five Residents (Residents #6, #15, #1, #85 and #97) of 20 residents reviewed for nursing services. The facility failed to ensure that the facility had sufficient staffing to meet the needs of Residents #6, #15, #1, #85 and #97. This failure could affect and diminish the resident's quality of life by potentially placing the residents at risk of not receiving timely care or receiving nursing interventions to meet the resident's needs, risk of injury, risk of safety, and/or it can make the resident feel neglected affecting their mental health and overall psychosocial well-being not being met by facility staff.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #9, Resident #53, and Resident #101) reviewed for resident rights. The facility failed to ensure CNA H knocked on Resident #9's and Resident #101's doors before entering the residents' rooms. The facility failed to ensure CNA A closed Resident #53's door during peri-care (cleaning of the private areas). These failures could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress.
- E
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This failure could place residents at risk of not receiving mail in a timely manner and a diminished quality of life.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews, and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of seven residents ( Resident #85, Resident #1, and Resident #97) reviewed for activities. The facility failed to provide Resident #85 and Resident #1 in room activities since their admission on [DATE] for Resident #85, on 08/07/2025 for Resident #1 and Resident #97 post hospitalization during two weeks of August 8th thru August 22nd, 2025. [...]
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interviews, and record review, the facility failed to have sufficient staff with the appropriate competencies and skill sets to provide quality care for 1 of 12 staff reviewed for nursing services. The facility failed to ensure that MA M renewed her certified nurse aide license. This failure could affect and diminish the resident's quality of life by potentially placing the residents at risk of not receiving competent and skilled care to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident according to their individual comprehensive care plans.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for 3 of 15 (Resident #12, Resident #91, and Resident #96) residents reviewed for pharmacy services. The facility failed to ensure MA administered Resident #12's 9:00a.m. scheduled time-sensitive medications until 1.5 - 3 hours after the ordered time on 09/07/2025. The facility failed to ensure MA G administered Resident #91's 9:00a.m. scheduled time-sensitive medications until 1.5 - 3 hours after the ordered time on 09/07/2025. The facility failed to ensure MA L administered Resident #91's 9:00a.m. scheduled time-sensitive medications until 1.5 - 3 hours after the ordered time on 09/11/2025. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure food items were labeled and dated with the received or expiration date. 2. The facility failed to properly store food in the pantry and freezer. 3. The [NAME] failed to wash her hands and change gloves between puree tasks. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure a new resident was not admitted with mental illness unless the state mental health authority determined eligibility, based on independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission for 1 of 12 residents (Resident #66) reviewed for PASRR services. The facility failed to ensure a positive PASRR screening was sent to the mental health authority for Resident #66. This deficient practice could place residents at risk for not obtaining the services needed to treat their mental health diagnoses.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased 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 infections for 1 of 5 residents (Resident #97) reviewed for infection control. The facility failed to ensure CNA E was following infection control protocol during urinary catheter care and peri-care for Resident #97 by not changing her gloves when cleansing the catheter tubing and doing peri-care on 09/10/25. This failure could place residents at risk of transmission of disease and infection.
May 27, 2025Complaint inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #1) of 7 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1's comprehensive MDS assessment dated [DATE] accurately reflected her use of dentures and having no natural teeth. This deficient practice could have placed the resident at risk for inadequate care due to inaccurate assessments.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 7 residents (Resident #1) who were reviewed for care plans. The facility failed to develop a person-centered care plan for Resident #1's oral care needs related to denture use despite a dentists' visit and cleaning of her dentures on 4/21/25. This failure could place residents at risk of their needs going unmet, unintentional weight loss, and/or feelings of self-consciousness.
August 22, 2024Standard inspection · 9 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure the griddle was kept clean and free from build-up of grease and food crumbs. This failure could place residents at risk of food borne illnesses and cross contamination.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two of eight residents (Residents #42 and #32) reviewed for resident rights. The facility failed to ensure Residents #42 and #32 were kept clean shaven. This failure could place residents at risk of a decreased sense of self-worth.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #4) reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #4's catheter. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming for two of eight residents (Residents #42 and #32) reviewed for resident rights. The facility failed to ensure Residents #42 and #32 were kept clean shaven. This failure could place residents at risk of a decreased sense of self-worth.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #6) reviewed for accidents and hazards. NA B failed to follow policy for transferring residents with mechanical lift devices while transferring Resident #6, resulting in him falling. This failure could place residents at risk for falls and injuries.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 6 residents (Resident #101) reviewed for respiratory care. The facility failed to replace Resident #101's oxygen humidifier bottle when it was empty. This deficient practice could place residents at-risk for respiratory infection, and ineffective treatment.
- D
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.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 26 residents (Resident #92) reviewed for storage of medication. The facility failed to ensure Resident #92 did not have Dulcolax Docusate Sodium 100 mg/Stool Softener Laxative stool softener stimulant-free stored at the resident's bedside table. This failure could place residents at risk of accessing medications not prescribed to them and overdosing.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased 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 infections for 1 of three residents (Residents #43) reviewed for infection control. RN H failed to don a gown before providing bolus feeding to Resident #43, who was on Enhanced Barrier Precautions. This failure could place residents at risk of contracting an infection from residents on Enhanced Barrier Precautions and cross contamination, which could result in infections or illness.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for the facility. The facility failed to have sufficient justification for antibiotic use when Resident #57 was prescribed antibiotic treatment for UTI on 11/11/23 and it was not discontinued. This failure placed the resident at risk for unnecessary antibiotic medication and increased risk of multi-drug resistant organism (MDRO) infections.
May 31, 2024Complaint inspection · 1 citation
- K
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services to include the acquiring and administering of medications to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 received his prescribed anti-convulsant medications (medications to prevent seizures) for eight days (16 doses) from 5/17/2024 until 5/25/2024. Resident #1 had a seizure on 5/25/2024 and was sent to the ED for emergent care, returned to the facility on 5/26/2024 and had another seizure on 5/27/2024 and was sent back to the ED. The noncompliance was identified as PNC. The IJ began on 5/28/2024 and ended on 5/29/2024. The facility had corrected the noncompliance before the survey began. [...]
May 23, 2024Complaint inspection · 3 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 7 residents (Resident #2) who were reviewed for accommodation of needs. The facility failed to ensure Resident #2's call light were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment, for 1 of 7 residents (Resident #1) reviewed for residents' rights. The facility failed to keep Resident #1's room free of trash. This failure could lead to residents being harmed due to falls, feeling uncomfortable in their surroundings, or becoming sick due to spread of germs. Findings Included: [...]
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 7 residents (Resident #2) reviewed for physical environment. The facility failed to ensure Resident #2 had a working call light in the room. This failure could place residents at risk of not being able to get assistance when needed.
June 29, 2023Standard inspection · 1 citation
- E
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide or obtain radiology services to meet the needs of its residents to include timeliness of the services for two (Resident #70 and Resident #8) of 18 residents reviewed for radiology and diagnostic services. 1. LVN A failed to request x-ray orders to be STAT (referring to a diagnostic or therapeutic procedure that is to be performed immediately; prioritized in a lab, as the results have a potentially immediate impact on patient management) for Resident #70 after reporting pain to her left hand and hip due to a fall on 06/20/23. 2. LVN A failed to obtain and enter x-ray orders for Resident #8 after being informed by Hospice on 06/22/23 regarding Resident #8 complaining of knee pain. These failures placed residents at risk of a delay in treatment.
Fire safety inspections
16 fire safety citations on file: 1 on September 11, 2025, 10 on August 22, 2024, 5 on June 29, 2023.
Every fire safety citation16 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 29, 2023 · Corrected (the home has a date of correction)