10851 Crescent Moon Dr., Houston, TX 77064 · Harris County · (281) 955-4100
202 certified beds, about 63 residents a day · For profit - Partnership · Medicare and Medicaid since 1989
CMS Care Compare ratings, data as of September 1, 2026 · CCN 455815 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 3, 2026, inspectors cited 5 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 43 health citations since February 2024, 8 were rated as actual harm or immediate jeopardy to residents (5 immediate jeopardy).
CMS lists 3 fines totaling $77,357 in the last three years; the largest was $46,008, and the latest is dated April 29, 2026.
Nurses and nurse aides worked 3.33 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.39 of those hours.
59.7% of nursing staff left within the year CMS measured (Texas average 55.3%).
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 interviews and record review, 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, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #27 and Resident #40) out of 8 residents reviewed for reporting. [...]
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 2 of 2 hallways (Halls 100 and 200), 1 of 26 rooms (room [ROOM NUMBER]), and the kitchen reviewed for pest. The facility had live flies in areas of the facility including Hall 100, Hall 200, and room [ROOM NUMBER].-The facility failed to ensure the kitchen was free of pest when a fly was observed to land on uncovered bread prepared for the lunch meal service on 07/01/2026. This failure could place residents at risk for foodborne illness, disease, decreased health, safety and decreased quality of life.
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(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 3 residents (Resident #27) reviewed for notification of changes. The Weekend Supervisor failed to notify the physician and RP when Resident #27 had an unwitnessed fall on 05/03/2026. These failures could place residents at risk of delay in treatment, worsening of conditions, hospitalization, and responsible party not being informed in care decisions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and resident choice for 1 of 3 residents (Resident #27) reviewed for falls. The facility failed to ensure Resident #27 was assessed after an unwitnessed fall. This failure placed residents at risk of delay in care, worsening of injuries.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 (100-hall med cart) of 4 med carts reviewed for medication storage. The 100-hall nursing medication cart had an insulin pen labeled for Resident #1 and was not labeled with an open date. This deficient practice could place residents at risk of not receiving expired medications and or the intended therapeutic benefit of their medications, resulting in a decline in health status.
Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents were free from abuse and neglect for 1 of 5 residents (CR#1) reviewed for ADL Care. The facility failed to ensure CR#1 was free from neglect when she was told to poop in her diaper and left to sit in her feces for 2 hours. This failure could place residents at risk of developing skin associated wounds needing continued medical assistance. FindingsRecord review of CR#1's undated face sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and discharged from the facility on 3/30/2026. Resident #3 had a diagnosis of type 2 (obtained later in life) Diabetes with hyperosmolarity (body doesn't make enough insulin in the body); legally blind (unable to see), dependence on renal dialysis (treatment for people with failing kidneys), hypertension (high blood pressure). [...]
Inspectors wroteBased on interviews, and record review, the facility failed to provide services and make reasonable accommodations to meet the Residents needs and preferences, for 4 of 5 residents reviewed for quality of life (CR#1, Resident #2, Resident #3, and Resident #4) reviewed. Resident rights Facility failed to ensure nursing staff responded to resident call lights within a reasonable time frame. Interviews were CR #1, Resident #2, Resident #3, and Resident #4 revealed their call lights frequently went unanswered for up to one hour or longer. This should practice had the potential to place residents at risk for unmet needs, including delays in receiving assistance with medical care in the event of an emergency.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff possessed the appropriate competencies and skill sets necessary to provide safe care for 1 of 3 residents reviewed for nursing services (Resident #1). The facility failed to ensure CNA G implemented safe transfer measures on 02/13/2026 at 4:00 a.m. when she attached the lift sling to the handling strap, instead of the sling attachment loop. Resident #1 experienced a fall and sustained a fractured clavicle during a mechanical lift transfer. The DON was unable to demonstrate proper mechanical lift transfer technique or clearly explain required safety measures. The facility was unable to provide documentation verifying that CNA G, CNA A, CNA B, or other direct care staff had demonstrated competency in mechanical lift transfers prior to performing resident care. On 02/23/2026 at 2:11p.m. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents (Resident #1). The facility failed to ensure CNA G implemented safe transfer measures on 02/13/2026 at 4:00 a.m. when she attached the lift sling to the handling strap, instead of the sling attachment loop. Resident #1 experienced a fall and sustained a fractured clavicle during a mechanical lift transfer. On 02/22/2024 at 8:22p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/25/2026, the facility remained out of compliance at a severity level of at a potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes 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 #6) reviewed for care plans .The facility failed to ensure a care plan was developed to address Resident #6's need for an escort to appointments. This failure could place residents at risk of not receiving appropriate care and interventions to meet their needs.
Inspectors wroteBased on observation. interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #6) reviewed for adequate supervision and accident hazards. The facility failed to ensure Resident #6 had an escort to a clinic visit on 12/31/2025 at 2:30 PM.This failure could place residents at risk of injury and lack of support during off-site visits.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #68) of 5 residents reviewed for accurate records.-The facility failed to document showers for Resident #6 on 12/30/2025, 1/1/2026, 1/3/2026, 1/6/2026, 1/6/2026, 1/10/2026 and 1/13/2026.-The facility failed to upload documents or have progress notes related to Resident #6's clinic visit on 12/31/2025. This failure could put residents at risk of changes in condition such as skin injury or breakdowns not being detected and treated and resident progress not being tracked.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents, who was dependent on assistance for activities of daily living, received necessary and timely care and services, including repositioning, incontinence care, and bathing, in accordance with professional standards of practice for 1 of 5 residents reviewed (Resident #1). On 01/13/2026, the facility failed to ensure Resident #1 received repositioning, incontinence care, or a scheduled bed bath. This failure could place residents at risk of not receiving timely hygiene care and demonstrated inadequate oversight of staff responsibilities related to activities of daily living. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts were secured for 3 of 5 medication carts (MC #1, MC #2, and MC #3) reviewed for drug storage and labeling. The facility failed to ensure MC #1, MC #2 and MC #3 were locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 6 residents reviewed for quality of care. -On 09/14/25, CNA A failed to tell Nurse A specifically what was wrong with CR #1. Nurse A failed to assess or provide medical care for CR #1 for approximately two hours, after CNA A asked her to check on CR #1 around 6:30 p.m. CNA A called 911 on 09/14/25 around 8:46 p.m. after CR #1 was noted to have a fever of 103 F, nausea/vomiting, doubled over with pain of 10/10, and was grayish in color. CR #1 was diagnosed at the hospital with fever, left heel wound infection, complicated UTI, and AKI. An Immediate Jeopardy (IJ) was identified on 10/07/25. The IJ Template was provided to the facility on [DATE] at 2:05 p.m. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 6 residents reviewed for resident rights. - Nurse A did not immediately notify CR #1's physician when he had a change in condition and was sent out to the hospital via 911 on 09/14/25. -Nurse A did not notify CR #1's family member/RP/emergency contact when he had a change in condition and was transported to the hospital on [DATE]. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident has a right to a dignified existence and maintain good grooming at resident request in a timely manner for two out of four residents (Resident#2 and Resident #1) reviewed residents rights. The facility failed to provide timely incontinent care for Resident #2 and Resident #1 and it affected the resident's feelings. This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth Record review of Resident #2's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and need assistance with personal care. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 4 residents (Resident#2 and Resident #1) reviewed for ADLs. The facility failed to provide timely incontinent care for Resident #2 and Resident #1. This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care. The facility failed to ensure CNA L and CNA D properly cleaned Resident #1 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization.
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 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA L and CNA T followed appropriate infection control, hand hygiene and PPE procedure during incontinent care for Resident #1. This failure could place residents at risk for infection.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside, and toilet and bathing facilities for 1 of 5 residents (Resident #1) reviewed for call light systems. The facility failed to ensure Resident #1' s call light was properly functioning. These failures could place residents at risk of not being able to call for assistance when needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident's choice for 1 of 7 (Resident #1) reviewed for Quality of Care. 1. The facility failed to call emergency services and have Resident #1 immediately transferred to the hospital, on 08/09/25 when she experienced a change in condition at 11:30 a.m., including a blood pressure reading of 203/98 and a change in mental status. The facility failed to monitor Resident #1 after the change in condition was noted and used a non-emergency ambulance service, which resulted in a delay in her receiving emergency care until after 1:13 p.m., approximately one hour and 51 minutes after her initial change in condition. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 4 residents (Resident #21and Resident #31) reviewed for ADLs. - The facility failed to ensure Resident #21was provided personal grooming (dry patches and flaky skin) by facility staff. - The facility failed to ensure Resident #31 was provided personal grooming (brown substance in the resident fingernails) by facility staff. These failures could place residents at risk for not receiving the assistance needed for daily care and services.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 4 residents (Resident #31 and Resident #14) observed for infection control. The facility failed to ensure EBP sign was posted on Resident #31 door and ensure PPE was set up at the residents door. The facility failed to ensure clean uncovered linen cart with linens was not stored in Resident # 14 room. These failures could place the residents at risk for infection.
Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs and preferences reviewed for accommodation of needs. for one resident (Resident #28) of 15 residents. The facility failed to ensure Resident #28's call light was within reach of the resident. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.
Inspectors wroteBased on observation, interview, and record review the facility failed to respect the resident's right to personal privacy during care, for 1(Resident # 777) of 6 residents reviewed for privacy, in that: -LVN F failed to lock her computer during medication pass on 04/09/25, leaving Resident #777's medical records disclosed on the hallway. This failure could place resident at risk for economic harm, embarrassment, and not maintaining their individual autonomy and individuality.
Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered baseline admission care plan for 2 of 6 residents (Resident #45 and Resident #31 ) reviewed for baseline care plans in that: -The facility failed to develop a 48-hour baseline care plan with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #45. - The facility failed to develop a 48-hour baseline care plan with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #31. This failure could affect new admissions residents reviewed for 48-hour baseline care plans of not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health.
Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Resident #53, Resident #31) reviewed. The facility failed to ensure that Resident #53's status of hospice were a focus area in the resident's comprehensive care plan and no intervention was in place. The facility failed to ensure Resident #31 status on ADL care were a focus area in the resident's comprehensive plan and intervention was in place. This deficient practice could affect residents by contributing to inadequate care.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #158) of 6 residents reviewed for range of motion. -Resident #158 did not receive preventive care measures to prevent further contractures of the resident's hands. This failure placed resident at risk for impaired skin integrity, of further decline and decrease in their quality of life and quality of care.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 3 residents (Resident #45) reviewed for accident hazards, in that: The facility failed to ensure there was no unattended container micro - kill germicidal wipes on top of the housekeeper's cart in 100 hall. These deficient practices could place residents at risk of an accidental injury.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who enters the facility with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #17, Resident #158) of 6 residents reviewed for catheters, as evidenced by: -Resident #17 did not have a STATLOCK to secure Foley catheter. -Resident #158 did not have a STATLOCK to secure Foley catheter. These failures placed the residents at risk of their Foley catheters getting dislodged, unwanted pain, trauma, infections, and decreasing their 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 stored properly in accordance with professional standards of practice in one of two medication rooms (Hall 100), reviewed for labeling and storage of drugs and biologicals, in that: -Medication room on hall 100 had expired medications. These failures placed residents on Hall 100 at risk of receiving expired medications and adverse reactions. Findings Include: Observation on 04/09/25 at 7:15AM on Hall 100 medication storage room revealed there were 3 expired hydrocortisone acetate 25mg suppositories. The expiration date on the medication was dated 03/2025. Interview on 04/09/25 at 7:25AM with LVN H said it was the DON that was supposed to be checking the medication rooms for any expired medications. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 out of 3 dumpsters, dumpster A. -On 4/8/2024 at 8:08am, one of the facility's dumpster was observed with no lid attached or on it and was a quarter full. This failure has the potential to affect 54 residents in the facility, staff, and visitors by placing them at risk for infection and a decreased quality of life due to having an exterior environment which could attract pests, rodents and other animals.
Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (CR #1) of 7 residents reviewed for controlled drugs in that: -The facility failed to appropriately store CR #1's Norco oral tablet 5-325mg (Hydrocodone -Acetaminophen- medication classified as a schedule II drug (high potential for addiction and abuse) used to treat pain and also used as a cough suppressant) in the DON's office under double lock when CR #1 was discharged to the hospital on [DATE] and returned to the facility 06/21/24. It was discovered on 06/29/24 that the medication was missing after CR #1 requested pain medication. [...]
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 1 of 4 residents (Resident #21) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure Resident #21 who the facility staff knew he was at risk for fall and update fall precaution interventions after several falls resulting in injuries to the head. An IJ was identified on 02/09/24. The IJ template was provided to the facility on [DATE] at 7:15 p.m. While the IJ was removed on 02/11/24 at 12:50 p.m., with the Administrator, DVP and DVP Clinical. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a Resident #28 who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 (Resident #28) of 4 residents reviewed for ADL's and quality of life. The facility failed to ensure Resident #28 was provided incontinent care in a timely manner, which resulted in decreased skin integrity. This failure affected one resident (Resident #28) and placed residents requiring assistance with incontinent care at risk of not have the assistance with personal care which could cause pain, skin breakdown, lack of dignity and low self-esteem.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one resident (Resident #28) of 5 residents reviewed quality of care and skin . The facility failed to assess, report, and obtain new physician orders due to a change in resident #28's skin condition of the perineal (private area of a patient) groin and buttock to the physician. This failure affected one resident (Resident #28) out of 4 residents reviewed for skin issues and had the potential to place residents at risk skin break down, infection and discomfort.
Inspectors wroteResident #16 Review of Resident #16's face sheet dated 02/06/24 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and 12/23/23 with diagnoses including quadriplegia (paralysis of all four limbs), hypoxia (a condition in which the human body tissues are not oxygenated sufficiently to maintain adequate homeostasis), muscle weakness (generalized), seizures( sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), familial dysautonomia ( a nervous system disorder that disrupts autonomic body processes), bipolar disorder ( mental illness that causes unusual shifts in a person's mood, energy) unspecified, aphasia ( unable to speak), tracheostomy( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck), tachycardia ( a [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent decrease in range of motion for 1 of 5 residents (Resident #16) reviewed range of motion. -The facility failed to ensure Resident #16, with contractures to both hands, was wearing a hand rolls on both hands and off load bilateral heels. as care planned and ordered by the physician. - This failure could place resident at risk for further contractures of the hands and fingers, pain, and a decrease in quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents ( Resident #16 and Resident #89) reviewed for incontinent care, in that: CNA B did not separate Resident #16's labia to clean during incontinent, clean arround the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care CNA A did not separate Resident # 89's labia to clean during incontinent, clean arround the buttock and did not perform appropriate hand hygiene with glove changes throughout the care. This deficient practice could affect residents who received perineal care( the skin in between your genital and your anus) and place them at-risk of increased urinary tract infections due to improper care.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services was provided such care, consistent with professional standards of practice for 1 of 4 residents (Resident #6) reviewed for respiratory therapy in that: The facility failed to ensure Resident # 6's concentrator filter was not covered with a substantial amount of dust. This failure placed residents who received oxygen therapy at risk of respiratory complications.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (skilled unit MA cart, 300 hall nurse cart, and 200 hall nurse cart) reviewed for medication storage. - The 300-hall nurse's cart contained an opened fluticasone propionate nasal spray with no discard date. Cyclosporine ophthalmic emulsion 0.05% was not in the complete original packet. A box of quality choice original eyelid cleansing wipes did not have a visible expiration date. -The 200-hall nurse's cart contained a box of quality choice original eyelid cleansing wipes without a visible expiration date. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 2 residents (Resident #16 and #89) reviewed for infection control. 1. CNA B failed to perform hand hygiene appropriately while providing incontinent care for Resident #16 by not changing gloves and washing hands. 2. CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #89 by not changing gloves and washing hands. These failures could place residents at risk for transmission of diseases and organisms.
25 fire safety citations on file: 6 on July 3, 2026, 8 on April 11, 2025, 11 on February 11, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| April 29, 2026 | Fine | $19,610 |
| February 27, 2026 | Fine | $11,739 |
| August 16, 2025 | Payment Denial | 24 days from September 17, 2025 |
| February 11, 2024 | Fine | $46,008 |
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) | 3.33 | 3.39 | 3.86 |
| Registered nurses | 0.39 | 0.43 | 0.69 |
| All nursing staff on weekends | 2.94 | 2.98 | 3.42 |
| Nurse aides | 2.09 | ||
| Licensed practical nurses | 0.85 | ||
| Nursing staff turnover (share who left in a year) | 59.7% | 55.3% | 45.8% |
| Registered nurse turnover | 80.0% | 54.6% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.80 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 3.49 on weekdays and 2.94 on weekends, 16% 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 3.71 in April to June 2025 to 3.33 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 | 3.33 | 0.39 | 3.49 | 2.94 | 0.0% | 4 of 90 | 63 |
| Oct to Dec 2025 | 3.27 | 0.50 | 3.45 | 2.81 | 0.0% | 4 of 92 | 62 |
| Jul to Sep 2025 | 3.21 | 0.52 | 3.38 | 2.77 | 0.0% | 0 of 92 | 61 |
| Apr to Jun 2025 | 3.71 | 0.32 | 3.90 | 3.22 | 0.0% | 0 of 91 | 56 |
| 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.
| 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 | 20.1 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.9 | 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 | 20.2 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 9.3 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 15.3 | 9.6 | 15.4 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Fallbrook Rehabilitation and Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (30.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
30.7% this home
No different from the national rate
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. 28 eligible stays.
12.2% this home
No different from the national rate
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. 28 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. 15 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. 27 residents counted.
2.2% 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. 27 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. 4 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: FRIO HOSPITAL DISTRICT.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Frio Hospital District | 5% or greater direct ownership interest | Organization | 02/01/2024 | |
| Ruff, Michael | Corporate officer | Individual | 02/01/2024 | |
| Crescent Moon Dr Consulting LLC | Operational/managerial control | Organization | 02/01/2024 | |
| Hiscox, Kenneth | Operational/managerial control | Individual | 01/13/2025 | |
| Miller, William | Operational/managerial control | Individual | 02/01/2024 | |
| Vakil, Rupesh | Operational/managerial control | Individual | 02/01/2024 | |
| Crescent Moon Dr Consulting LLC | Adp of the SNF | Organization | 04/09/2025 | |
| Hiscox, Kenneth | Adp of the SNF | Individual | 04/09/2025 | |
| Vakil, Rupesh | Adp of the SNF | Individual | 04/09/2025 |
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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