7514 Kingsley St., Houston, TX 77087 · Harris County · (713) 644-8393
169 certified beds, about 77 residents a day · For profit - Individual · Medicare and Medicaid since 1987
CMS Care Compare ratings, data as of September 1, 2026 · CCN 455682 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 11, 2026, inspectors cited 8 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 43 health citations since September 2023, 16 were rated as actual harm or immediate jeopardy to residents (13 immediate jeopardy).
CMS lists 3 fines totaling $71,011 in the last three years; the largest was $45,760, and the latest is dated January 14, 2026.
Nurses and nurse aides worked 3.59 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.57 of those hours.
CMS links it to Creative Solutions in Healthcare, an affiliated group of 149 nursing homes.
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.
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 43 health citations on file.
Inspectors wroteBased on interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 19 Residents (Resident #82) reviewed for care plans. -The facility failed to develop and implement a care plan regarding Resident #82's history of suicidal ideations. This failure could place residents at risk of not having their needs met or inability of staff to identify a change of condition. [...]
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to establish accurate acquiring, dispensing and administering of controlled medications and a system of accurate medication records that enabled periodic reconciliation and accounting of all controlled medications to meet the needs of 1 of 4 residents (Residents #61) reviewed for pharmacy services. The facility failed to ensure that controlled drug records were accurate for Resident #61 and that an account of all controlled drugs was maintained and periodically reconciled. The facility failed to ensure controlled medication for discharged Resident # 5 and Resident #76 on 300 B Hall Nurse's cart were removed within 3 days upon their discharge from facility. The facility failed to ensure discontinued medications for Resident # 31, Resident #56, and Resident #36 were removed from 300 B Hall nurse's cart. [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 20% based on 5 errors out of 25 opportunities, which involved 5 of 5 residents (Resident #3, Resident # 48, Resident #28, Resident #64 and Resident #51) reviewed for pharmacy services. The facility failed to ensure MA A accurately verified and administered Hydralazine 25mg as per physician's order for Resident #51. The facility failed to ensure MA B properly verified and administered timely manner as per physician's order. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. -The facility failed to ensure their stove pilot light was working properly, on 6/8/26, causing natural gas to flow into the kitchen and dining room area. --The facility failed to ensure [NAME] E used proper hand hygiene while preparing food items. On 6/9/26, [NAME] E did not remove her gloves and perform proper hand hygiene after cleaning kitchen countertops, obtaining ice from the ice machine, retrieving cooking utensils from the floor and drawer, then preparing the resident's lunch.-The facility failed to ensure two juice dispenser tubes were kept off the floor on 6/8/26. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided accurate Preadmission Screening and Resident Review (PASRR) screening for 1 of 19 residents (Resident #3) reviewed for resident assessments. The facility did not correctly identify Resident #3 as having a mental disorder on their PASRR Level 1 Screening. This failure could place residents with mental disorders at risk of not receiving specialized PASRR service which could contribute to a decline in physical, mental, psychosocial well-being, and quality of life.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure adequate supervision to prevent accident hazards for one (Resident #53) out of five residents reviewed for quality of care. The facility failed to ensure Resident #53 was supervised while smoking and receiving oxygen therapy. This failure could place residents at increased risk of fires and burns.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who is diagnosed with Dementia received the appropriate treatment and services to maintain his/her highest practicable physical, mental and psychosocial well-being for one (Resident #2) of five residents reviewed for behavioral health. The facility failed to ensure Resident #2's dementia diagnosis was addressed in her plan of care goals and interventions. This failure could place residents at risk of significant cognitive decline and a decrease in quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were properly discarded and the medication storage room was maintained in accordance with currently accepted professional principles for 1 (100 Hall) out of 2 medication storage room and 2 (300 B Hall) out of 3 medication carts reviewed for pharmacy services. The facility failed to ensure 100 Hall medication storage room did not have non-medical items. The facility failed to ensure expired medications for Resident # 28 was removed from 300 B Hall nurses' cart and MA cart. These failures could place residents at risk of receiving discontinued medication, receiving potentially harmful side effects from expired prescribed medications and drug diversion.
Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 residents ( Resident #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to prevent Resident #1 from falling to the floor and injuring himself during patient care on 01/09/26 and resulted in a laceration to his upper lip which required stitches. This deficiency could expose residents to harm and injury, due to not being adequately monitored.
Inspectors wroteBased on interviews and record review the facility failed to ensure the resident environment remained free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (CR #1's) reviewed for adequate supervision. -The facility failed to provide adequate supervision to prevent CR #1 from eloping from the facility at an unknown time on 9/21/25. This deficiency exposed residents living in the facility to potential harm, injury, or death due to not being adequately monitored. An Immediate Jeopardy (IJ) was identified on 11/18/25. The IJ template was provided to the facility on [DATE] at 4:41 pm. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 13 residents (Resident#2) reviewed for resident rights. 1. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 2. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be free from neglect for 2 of 13 residents (CR#1 and Resident #2) reviewed for neglect.1. The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE].2. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.3. The facility failed to notify Resident #2's Physician when she was unable to receive Hemodialysis treatment as ordered on 10/03/2025. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, a residents with pressure ulcers received necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 13 residents (CR #1 and Resident #2) reviewed for pressure ulcers. -The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE]/2025. 2.--The facility failed to identify and treat the wounds of Resident #2 from admission on [DATE]-[DATE]. An Immediate Jeopardy (IJ) situation was identified on 10/11/2025. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (Resident #2) reviewed for pain. -The facility failed to ensure that pain management was provided for Resident #2, who was crying in pain, during the treatment of her 14 individual wounds. -The facility failed to assess Resident #2 accurately and appropriately, for pain prior to Resident #2 receiving wound care treatments for 14 separate wounds. -The facility failed to provide timely medication interventions for Resident #2's pain management for daily wound care treatments of her 14 individual wounds. An immediate Jeopardy (IJ) was identified on 10/10/2025. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 4 residents (Resident #2). The facility to ensure that Resident #2 received hemodialysis as ordered on 10/03/2025, which resulted in her not receiving any hemodialysis for a total of four days. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 PM. While the Immediacy was removed on 10/16/2025 at 7:43 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure placed residents at risk for delayed treatments, and actual harm. Findings Include: [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #2) - The facility failed to administer Resident#2's IV antibiotic as ordered from her admission on [DATE]-[DATE]. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 pm. While the Immediacy was removed on 10/19/2025 at 5:44 pm, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure had the potential to place residents at risk for delayed treatment, and worsening infections which can lead to actual harm. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for homelike environment. Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for homelike environment. The facility failed to ensure Hall 300 was free of odors. The facility failed to deodorize Resident #21 and Resident #31's room resulting in foul orders filling the 300 Hallway and other residents rooms on the 300 hall resulting in complaints from other residents and family members. [...]
Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for physical environment. Based on observation, interviews, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for physical environment. The facility failed to ensure Hall 300 was free of odors. The facility failed to deodorize Resident #21 and Resident #31's room resulting in foul orders filling the 300 Hallway and other residents rooms on the 300 hall resulting in complaints from other residents and family members. [...]
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 4 hallways, (Hall 300) and Resident #21's and Resident #31's room. The facility had live flies in areas of the facility including Halls 300, and Resident #21 and Resident #31's room. This failure could place residents at risk for decreased health, safety and quality of life.
Inspectors wroteBased on , interview and record review the facility failed to ensure the resident had the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law for 1 of 13 residents (Resident #7) reviewed for resident rights. The facility failed to establish if Resident #7 wished to designate a Responsible Party at the time of his admission on [DATE] when he was alert and oriented and able to make his wishes known. This failure could place residents at risk for a diminished quality of life, loss of dignity and loss of self-worth.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 1 resident (Resident #2) reviewed for adequate supervision. The facility failed to provide adequate supervision to prevent Resident #2 from eloping from the facility at 2:05 a.m. on 5/6/25 .The noncompliance was identified as Past Non-Compliance. The IJ began on 5/6/25 and ended on 6/6/25 . The facility had corrected the noncompliance before the survey began. The failure placed residents with wander guards at risk of serious harm or death.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the facility must include the expiration date when applicable and were not expired for two (100 Hallway medication aide medication cart and 400 Hallway nurse medication cart) out of three medication carts reviewed for medication storage and labeling. 1. The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma and other causes of high pressure inside the eye) were labeled with expiration date for Resident #32, Resident #35, and Resident #88. 2. The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma and other causes of high pressure inside the eye) was removed from the medication cart for Resident #28 as it was past its use by recommendation. 3. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure any medications were not given in excessive doses for 1 (Resident #90) of 7 residents reviewed for medication orders. The facility failed to ensure that Resident #90 did not recieve incorrect doses of medication. The failure could place residents at risk of receiving inaccurate administration of medications which could result in possible adverse effects or residents not receiving therapeutic benefits of medications.
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 service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to keep the dining room clean and free of dirty dishes with leftover food overnight 2. The facility failed to ensure that the rails along the vent hood was free of grease. 3. The facility failed to store and date foods stored in the refrigerator one of two refrigerator in the kitchen. 3. The facility failed to ensure that the dry good pantry was free from expired food product. These failures could place residents at risk for food borne illness.
Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Significant Change MDS assessment with 14 days after the facility determined, or should have determined, there has been a significant change in a resident's physical or mental condition for 1 of 25 residents reviewed for assessments (Resident # 31). --the facility failed to complete a Significant Change MDS for Resident # 31 within 14 days of the resident's discharge from hospice services. This failure placed residents who had a significant change in condition requiring an MDS assessment at risk of not receiving needed services.
Inspectors wroteBased on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 1 of 3 residents (Resident #48) reviewed for a mental illness, intellectual disability, or developmental disability. The facility failed to ensure Resident #48 who had a diagnosis of mental illness had a PASARR Level II (PE) screening completed. This failure placed residents at risk of mental health needs not being met.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 (Resident #362) of 7 residents reviewed for care plans. The facility failed to develop a baseline care plan, or a comprehensive care plan in place of a baseline care plan, for Resident #362 within 48 hours of admission. The failure could place residents at risk of not receiving effective person-centered care to achieve their highest practicable level of physical, mental, and psychosocial well-being.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 25 residents reviewed for care plan revision (Resident # 31). --resident #31's comprehensive care plan was not revised to reflect discharge for hospice services. This failure placed residents at risk of not receiving services according to their individual conditions.
Inspectors wroteBased on interview and record review, the facility failed to ensure any drug regimen irregularities were accurately reported by the Pharmacist Consultant for 1 (Resident #90) of 7 residents reviewed for pharmacy services. The facility failed to ensure that Resident #90 did not have duplicate medication orders. The failure could place residents at risk of receiving inaccurate administration of medications which could result in possible adverse effects or residents not receiving therapeutic benefits of medications.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was adequately supervised as a result she drank hand sanitizer and was hospitalized from [DATE]-[DATE]. This failure could place residents at risk of severe injuries, require hospitalization, or death due to lack of supervision by facility staff. Findings iIncluded: [...]
Inspectors wroteBased on interview, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good hygiene for 1 of 6 residents (Resident #2) reviewed for Activities of Daily Living. 1. Resident #2 had not been showered as scheduled on 3/10, 3/24, or 3/28/2025. These failures could place residents at risk of embarrassment, discomfort, and skin breakdown.
Inspectors wroteBased on observation, record review and interview the facility failed to thoroughly investigate and report an incident for 1 (Resident #1) of 6 reviewed for abuse and neglect. The facility failed to report Neglect after Resident #1 drank hand sanitizer. The facility failed to thoroughly investigate after Resident #1 got a hold of a bottle of hand sanitizer and drank it and was hospitalized on [DATE]. This failure could have placed residents at risk of abuse and neglect.
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 time frames 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 #3) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #3's had a care plan to reflect the residents' weight loss. 2. The facility failed to ensure Resident #3's had a care plan to reflect his medication Ozempic that was prescribed from November 2024 through February 2025. These failures could place residents at risk of not receiving adequate care and services to improve their quality of life.
Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Resident #3 and Resident #5) reviewed for pharmacy services. 1. The facility failed to ensure Resident #3 was administered his inhaler and supplement as ordered by his physician. 2. The facility failed to ensure Resident #5 was administered his Carvedilol oral tablet as ordered by his physician. These failures could place residents at risk of not being provided their medications as ordered which could result in dimishing quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 resident (Resident #1) reviewed for incontinent care. -The facility failed to ensure CNA A and CNA B properly cleaned Resident #1 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life.
Inspectors wroteBased on observations, interviews, 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 for 1 of 4 residents (Resident #1) reviewed for infection. CNA A failed to performed hand hygiene after removing soiled gloves before leaving Resident#1's room. This failure could place residents at risk for the spread of infection.
Inspectors wroteBased on interview and record review the facility failed to make prompt efforts by the facility to resolve grievances the resident may have, for 1 (Resident #30) of 16 residents reviewed for grievances. -1. The facility failed to follow-up and ensured Resident #30's missing property had been found or replaced. 2. The facility failed to complete the grievance process by following up with Resident #30 to see if his missing items were replaced, and the facility did not assist him with replacing his missing items. Resident #30 was missing his wallet that had his social security card, green card, cash app card, bank card, $10.00 and food stamp card. These failures could place residents at risk for missing property, emotional distress, and lack of resources needed to function and thrive at the facility.
Inspectors wroteBased on interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for 1 of 8 residents (CR#1) reviewed for abuse and neglect. The facility failed to conduct a thorough investigation and report to State Survey agency when CR #1, who was a total care resident, sustained a supra condylar femur fracture and required surgical procedure. The facility failed to protect CR #1 for over 24 hours while awaiting results of his suspicious injury of unknown origin. The facility failed to ensure their Abuse/Neglect policy was implemented and effective to prevent the further decline of CR #1. An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. [...]
Inspectors wroteBased on record review and interview the facility failed to develop and implement policies and procedures for ensuring the reporting of reasonable suspicion of a crime for 1 (CR #1) of 8 residents who was total care and sustained a femur fracture. 1. The facility failed to thoroughly investigate and report to State Survey agency that CR #1, who was a total care resident, sustained a supra condylar femur fracture and required surgical procedure. On 8/2/23 the resident was sent to the hospital and it was confirmed to be a supracondylar acute or subacute fracture. This suspicious injury of unknown origin should have been reported to the Administrator immediately. Interim Administrator A was not made aware of the incident until 8/3/23 a day later. Meanwhile the staff that had assisted CR#1 continued to work and no investigation was started. [...]
Inspectors wroteBased on record review and interview the facility failed to thoroughly investigate and report an injury of unknown origin for 1 (CR #1) of 8 reviewed for abuse and neglect. The facility failed to thoroughly investigate CR #1 injury of unknown origin which was suspicious due him being a total care resident with an impacted acute or subacute fracture of the supracondylar distal femur and a diagnosis of Quadriplegia. The facility failed to implement interventions to ensure CR #1 was safe after learning that his knee was swollen and was total dependent on staff for care. The facility failed to report the results of all investigations to officials in accordance with state law, including to State agency within 5 working days of the incident. An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision and to the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking areas, and smoking safety that also take into account nonsmoking residents for 3 of 23 residents (Resident #4, Resident #5 and Resident #6) reviewed for smoking policies. The facility failed to ensure CR #1 was free of accidents and injuries causing him to sustain a impacted acute or subacute fracture of the supracondylar distal femur that required surgical procedure. [...]
Inspectors wroteBased on observation, record review and interviews the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to ensure that residents were free from accidents and injuries for 1 (CR#1) of 8 reviewed for accident and injuries. The facility failed to follow their policy and procedure for investigating injuries of unknown origin after both Interim Administrator A and the DON became aware that CR#1 sustained an impacted acute or subacute fracture of the supracondylar distal femur. [...]
Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 8 residents (Resident #2 and Resident #3) reviewed for Activities of Daily Living. 1. The facility failed to ensure Resident #2's received incontinent care since the previous day which resulted in his adult brief, sheets and bed soaked with urine. 2. The facility failed to ensure Resident # 2 was given scheduled showers. 3. The facility failed to ensure Resident #3's adult brief was clean and dry. These failures could place residents at risk of embarrassment, discomfort, and skin breakdown.
7 fire safety citations on file: 4 on June 11, 2026, 1 on April 9, 2025, 2 on February 7, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| January 14, 2026 | Fine | $14,722 |
| October 27, 2025 | Fine | $45,760 |
| July 11, 2025 | Fine | $10,529 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.59 | 3.39 | 3.86 |
| Registered nurses | 0.57 | 0.43 | 0.69 |
| All nursing staff on weekends | 3.29 | 2.98 | 3.42 |
| Nurse aides | 2.18 | ||
| Licensed practical nurses | 0.84 | ||
| Nursing staff turnover (share who left in a year) | not reported | 55.3% | 45.8% |
| Registered nurse turnover | not reported | 54.6% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.72 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.71 on weekdays and 3.29 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.83 in April to June 2025 to 3.59 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.59 | 0.57 | 3.71 | 3.29 | 0.0% | 0 of 90 | 77 |
| Oct to Dec 2025 | 3.56 | 0.46 | 3.62 | 3.41 | 0.0% | 0 of 92 | 82 |
| Jul to Sep 2025 | 3.27 | 0.29 | 3.37 | 3.00 | 0.0% | 0 of 92 | 97 |
| Apr to Jun 2025 | 2.83 | 0.46 | 2.98 | 2.45 | 4.0% | 0 of 91 | 113 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 24.8 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.2 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.7 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.3 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 16.6 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.2 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 5.5 | 9.6 | 15.4 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Afton Oaks Nursing and Rehabilitation Center's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 19 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 22 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 12 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 13 residents counted.
0.0% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 29 residents counted.
9.1% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 28 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 7 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: WINNIE-STOWELL HOSPITAL DISTRICT. CMS links this home to Creative Solutions in Healthcare, a group of 149 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Murrell, Edward | Corporate director | Individual | 09/01/2024 | |
| Rollo, Jeffery | Corporate director | Individual | 09/01/2024 | |
| Stramecki, Anthony | Corporate director | Individual | 09/01/2024 | |
| Vratis, Kacey | Corporate director | Individual | 09/01/2024 | |
| Way, George | Corporate director | Individual | 09/01/2024 | |
| Diversicare Afton Oaks, LLC | Operational/managerial control | Organization | 09/01/2024 | |
| Journey Medical PLLC | Operational/managerial control | Organization | 01/20/2025 | |
| Winnie-Stowell Hospital District | Operational/managerial control | Organization | 09/01/2024 | |
| Bodie, Rebecca | Operational/managerial control | Individual | 09/01/2024 | |
| Garrett, Chandra | Operational/managerial control | Individual | 09/01/2024 | |
| Jian, Peter | Operational/managerial control | Individual | 01/20/2025 | |
| Nee, Stephen | Operational/managerial control | Individual | 09/01/2024 | |
| Weishaar, Matthew | Operational/managerial control | Individual | 09/01/2024 | |
| Garrett, Chandra | Adp of the SNF | Individual | 07/29/2025 | |
| Jian, Peter | Adp of the SNF | Individual | 07/29/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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