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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
9E
0F
Potential for minimal harm
0A
0B
0C
May 21, 2026Standard inspection · 8 citations
- E
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 observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment for 1 room and one hallway observed for environmental concerns. Resident #100's room had damage to furniture, base boards on every wall were separated from the wall, the bathroom had an area of rippled paint on the wall from ceiling to floor that appeared to be water damage. The hallway outside of Resident #100's room (Hallway 2100) had an area that had rippled paint, rust colored streaks originating from a wall mounted lighting unit, that extended from the ceiling to the floor. These affected areas affected could affect residents by placing them at risk for a decreased quality of life.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interviews and record reviews, the facility failed to notify the resident and/or resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 of 6 residents (Resident #4, Resident #38, and Resident #92) reviewed for discharge planning. The facility failed to notify Resident #4, Resident #38, and Resident #92 or their representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understood. The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #4, Resident #38, and Resident #92. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure that only disposable paper towels were disposed of in the garbage receptacle at handwashing sink #1. The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents. The facility failed to ensure dented cans were placed in a separate storage area. The facility failed to inspect produce inventory, monitor for spoilage or over ripening, and to discard spoiled, moldy, or over ripened food items. These failures could place residents at risk for food-borne illness, cross contamination, and infection. [...]
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an effective pest control program so that the facility was free from pests for 1 of 1 dining rooms and 1 (Resident #100) of 5 Resident rooms reviewed for environment. The facility failed to ensure the dining room was free of spiders. The facility failed to ensure Resident #100 room was free of roaches. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Resident #7) reviewed for accuracy of assessments. The facility failed to ensure Resident #7's MDS accurately reflected his diagnosis of an unconfirmed mass on his head. This failure could place residents at risk of receiving inadequate care and services. In a record review of Resident #7's face sheet, dated 05/20/2026, reflected the resident was an [AGE] year-old male initially admitted to the facility on [DATE]. [...]
- 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 interview and record review the facility 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 are identified in the comprehensive assessment for 1 of 6 residents (Resident #7) reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #7's diagnosis of an unconfirmed mass on his head. This failure could place residents at risk of not receiving appropriate interventions and care to meet their needs. In a record review of Resident #7's face sheet, dated 05/20/2026, reflected an [AGE] year-old male initially admitted to the facility on [DATE]. [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to keep garbage storage receptacles in a sanitary condition according to professional standards for 1 of 2 dumpsters and 1 of 1 industrial compactors: The facility failed to keep the outside garbage storage area clean. The facility failed to ensure 1 of 2 dumpsters and 1 of 1 industrial compactor were properly closed. This failure could place residents at risk of contracting disease by attracting pests and disease carrying rodents. During an observation on 05/21/2026 at 11:32 a.m., the facility's only outside trash dumpster area revealed:2 dumpsters and 1 compactor behind a 3-sided wooden gate, the back side was against the facility wall, and the gated door was open. The compactor door was open and had 3 cardboard boxes sitting on the outside of it. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, 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 one (Resident #22) of 5 residents, reviewed for infection control. The facility failed to ensure CNA H changed gloves and performed hand hygiene during incontinence care for Resident #22. This failure could place residents at risk for infection.
November 10, 2025Complaint inspection · 1 citation
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #1) of 5 residents reviewed for reasonable accommodations. The facility failed to provide a bed extension to accommodate resident preferences. This failure could place residents at risk of not being able to meet their needs.
August 16, 2025Complaint inspection · 1 citation
- 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, interviews, and record review, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for two (one medication cart for Hall 200 and one medication cart for Hall Burgundy on the rehab unit) of five medication carts reviewed for medication storage. 1. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when CMA A's one medication cart for Hall 200 were left unlocked and unattended by CMA A. 2. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys when LVN B's one medication cart for Hall Burgundy for Rehab and was left unlocked and unattended by LVN B. [...]
August 13, 2025Complaint inspection · 2 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 2 residents (Resident #1) reviewed for accidents. Resident #1 walked out of the facility unattended with a wander guard on and was missing for approximately 10 - 20 minutes on 05/01/2025. The noncompliance was identified as a PNC. The IJ began on 05/01/2025 and ended on 05/02/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for serious injury or death. Findings Include: Record review of Resident #1's face sheet dated 08/12/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident discharged to another from facility on 05/03/2025. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #1) of 2 for accuracy of records. The facility failed to accurately document an incident of elopement in progress notes that occurred r/t Resident #1. The failure can affect residents by putting them at risk of preventing further elopements r/t the lack of accurate documentation of incident.
June 18, 2025Complaint inspection · 1 citation
- J
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 the residents received adequate supervision and assistive devices to prevent accidents for one resident (Resident #1) of eight residents reviewed for assistive devices and supervision. - The facility failed to ensure Resident #1 received adequate supervision and care in accordance with professional standards when the resident complained of pain and MA B did not notify the nurse promptly. MA B transferred Resident #1 out of bed using a sit to stand lift without assistance and notified the nurse of Resident #1's pain afterwards. Resident #1 received an X-ray that was positive for an acute spiral fracture of her left femur. The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 6/18/25 at 1:00 PM. [...]
March 13, 2025Standard inspection · 2 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (2100 hall medication room) of two medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the east side medication room. These failures could place residents at risk for infection and having possible adverse effects.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to remove molded fruits. 2. The facility failed to ensure dented cans were placed in a separate storage area. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of walk-in refrigerator on 03/11/2025 at 9:27 a.m., revealed the following: -1 16oz bag of grapes dated 03/07/2025 contained molded grapes. -1 16oz container of strawberries dated 03/07/2025 contained molded strawberries. -2 6oz containers of raspberries dated 02/28/2025 contained molded raspberries. Observation of dry storage on 03/11/2025 at 9:35 a.m., revealed the following: [...]
February 19, 2025Complaint inspection · 1 citation
- E
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on interviews, and record reviews the facility failed to ensure professional staff were licensed, certified or registered in accordance with applicable state laws for one (ADON) of four licensed nursing staff reviewed for staff qualifications. The facility failed to ensure the ADON's Nursing license was not expired. The past noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for receiving nursing services by an unlicensed nurse.
December 18, 2024Complaint inspection · 2 citations
- K
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free of any significant medication errors for one (Resident #1) of four residents reviewed for medication errors. The facility failed to ensure Eliquis (anticoagulant commonly known as a blood thinner medication) was administered to Resident #1 as ordered from 08/26/2024 to 09/26/2024 (30 days). The noncompliance was identified as past noncompliance (PNC). The IJ began on 08/26/2024 and ended on 10/19/2024. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk for not receiving medications as ordered by their physician or per manufacturer's directions.
- J
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 (the process of receiving and interpreting prescriber's orders and to provide procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs) to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services. The facility failed to ensure the hospital discharge order to continue Eliquis (anticoagulant commonly known as a blood thinner medication) was accurately transcribed and administered to Resident #1 as ordered from 8/26/2024 to 9/26/2024 (30 days). The noncompliance was identified as past noncompliance (PNC). The IJ began on 8/26/2024 and ended on 10/19/2024. The facility had corrected the noncompliance before the state's investigation began. [...]
September 19, 2024Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, and record review, the facility failed to immediately report an allegation of abuse to HHSC for one (Resident #3) of five residents reviewed for abuse. The facility failed to report an allegation of abuse as required when Resident #3's family member reported to the facility that Resident #3 had been abused by PT B. This failure could place residents at risk for unreported allegations of abuse.
February 8, 2024Standard inspection, Complaint inspection · 4 citations
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview, and record review, the facility failed to inform each resident periodically during the resident's stay, of services available in the facility and charges for those services, including services not covered under Medicare/Medicaid and must inform the resident in writing at least 60 days prior to implemention of the change for one (Resident #185) of eight residents reviewed for [NAME] Services. The facility failed to develop, implement, and practice appropriate billing practices, subsequently Resident #185's room and board fees increased to $225.00 per day after his managed care insurance coverage ended on 12/24/22. The facility failed to notify Resident #185's RP about the increase in the resident's room and board fees on 12/24/22 to $225.00 per day; [...]
- E
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 all assistive devices were maintained and free of hazards for five (Residents #10, #12, #53, #69, and #183) of eighteen residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #10, #12, #53, #69, and #183. This failure could place residents at risk for equipment that is in unsafe operating condition, which could cause injury.
- 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, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. 2. The facility failed to ensure food in the facility's refrigerator, was not exposed from air-borne contaminants. 3. The facility failed to dispose of expired foods items in the refrigerator and freezer. These failures could place residents who receive food prepared in the facility's kitchen at an increased risk of exposure to food-borne illnesses.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, and record reviews 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 one (Residents #182) of eight residents reviewed for infection control. The facility failed to ensure Occupational Therapist G properly donned and doffed PPE by putting on an isolation gown before entering Resident #182's contact isolation room; additionally, when Occupational Therapist G left the resident's room, she took her gown off in the hallway then went back into Resident 182's room to dispose of the gown. Then afterwards she went to two other resident's rooms. [...]
Fire safety inspections
8 fire safety citations on file: 4 on May 21, 2026, 2 on March 13, 2025, 2 on February 8, 2024.
Every fire safety citation8 citations
- F
Provide properly protected cooking facilities.
K 324 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 21, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 13, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 8, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 8, 2024 · Corrected (the home has a date of correction)