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
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
8E
1F
Potential for minimal harm
0A
0B
0C
June 18, 2026Standard inspection · 6 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 provide a safe, clean, comfortable and homelike environment for 2 of 4 shower rooms (Shower Room D and Shower Room E) reviewed for environment. The facility failed to ensure Shower Room D was clean, sanitized and free from personal items on 6/17/26. The facility failed to ensure Shower Room E was clean and free from dirty linen and trash on 6/17/26. These failures could place residents at risk of exposure to infectious diseases, other unsanitary health hazards and affect their sense of dignity. An observation and interview of Shower Room D and Shower Room E with the Maintenance Director on 6/17/26 at 12:06 pm revealed a resident's wheelchair with rehab boots in the shower with no resident present. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to discard expired bread from the main kitchen. The facility failed to ensure bread was properly labeled and dated. These failures could place residents who received meals and/or snacks from the kitchen at risk of food-borne illness and food contamination if consumed. An observation on 06/16/26 at 9:30 a.m. in the facility's only kitchen revealed two unlabeled trays that contained 10 loaves of bread each. One loaf of bread reflected a best if used by date of 06/11/26 and contained four slices of bread with green mold. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1(Resident #25) of 4 residents reviewed for incontinent care. The facility staff failed to ensure Resident #25 was provided timely incontinent care on 6/16/26. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Record review of Resident #25's face sheet dated 6/16/26 reflected a [AGE] year-old male admitted on [DATE]. Resident #25 had the following pertinent diagnoses: [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 (Resident #8) of 3 residents reviewed for incontinent care. The facility failed to ensure CNA A and LVN B maintained the foley catheter drainage bag below Resident #8's bladder during a mechanical lift transfer on 06/16/2026. This failure could place residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Record review of Resident #8's Comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. [...]
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (medication cart hall C ) of 3 medication carts reviewed for pharmacy services and reviewed for storage in that: The facility failed to ensure one vial of TB serum (used to test if you have a tuberculosis germs in the body) that was opened and used was in the refrigerator and was dated on 6/16/26. This failure could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. Observation on 06/16/2026 at 12:01 p.m. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 resident (Resident #25) of 8 residents observed for infection control. The facility failed to ensure CNA E and CNA F changed gloves and performed hand hygiene during incontinent care for Resident #25 on 06/16/2026. These failures could place the residents at risk of cross-contamination and development of infection. Record review of Resident #25's Quarterly MDS assessment dated [DATE] reflected Resident #25 was a [AGE] year-old male admitted to the facility on [DATE]. [...]
April 9, 2026Complaint inspection · 1 citation
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's preferences related to television channels and volume; room temperature and bed position were included in his care plan. This failure could place residents at risk of their preferences not being honored and feeling uncomfortable in the facility. Record review of Resident #1's comprehensive care plan, revised on 12/19/25, reflected . [Resident #1] has an ADL self-care performance deficit r/t Activity Intolerance, Dementia (a decline in mental ability) Date Initiated: 07/15/2024 Revision on: [...]
January 14, 2026Complaint inspection · 1 citation
- D
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on interview and record review, the facility failed to ensure their activity program was directed by a qualified professional for 1 of 1 staff reviewed for activity professional qualifications. The facility failed to ensure the activities at the facility were directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional. This failure could place residents at risk of not receiving an effective activities program developed and implemented for their physical and mental well-being.
April 24, 2025Standard inspection, Complaint inspection · 9 citations
- 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 each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #329) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Resident #329 was missing from the facility for approximately 1.5 hours without any staff being aware until notified by the apartment complex staff. Resident crossed a parking lot and service road to get to the apartment complex. Review of [NAME] maps ( [NAME] Maps to Apartment Complex, [NAME], TX 75075) revealed the apartment complex was about 500 feet from the facility. The noncompliance was identified as Past Noncompliance (PNC) Immediate Jeopardy on 04/24/25. The noncompliance began on 03/18/25 and ended on 03/31/25. The facility had corrected the noncompliance before the survey began. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen and 2 (Dietary Manager and Dietary [NAME] O) of 4 Dietary Staff reviewed for Food and Nutrition Services. 1. The facility failed to ensure food items in the walk-in refrigerator and freezer were dated, labeled and sealed. 2. The facility failed to ensure 2 chest freezers had a thermometer while in use and failed to ensure temperature logs were maintained for the chest freezers. 3. The facility failed to ensure the Dietary Manager had a facial hair restraint for his mustache and used proper hand hygiene while handling and serving food during the lunch meal preparation and service on 04/09/25. 4. [...]
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to attain or maintain the resident's highest practicable mental and psychosocial well-being for 3 of 10 residents (Resident #73, #4, and #14) reviewed for Care Plans. 1. The facility failed to ensure Resident #73's comprehensive care plan reflected her psychotropic medications and ADL dependence. 2. The facility failed to ensure Resident #4's comprehensive care plan included her preference for bed baths and her specific ADL assistance needs. 3. The facility failed to ensure Resident # 14 care plan reflected she preferred her family member, Resident #33, to assist her with eating and assistance with activities of daily living. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #4 and Resident #289) of 8 residents reviewed for ADLs. 1. The facility failed to ensure Resident #4 had her fingernails cleaned and trimmed on 04/08/25 and 04/09/25. 2. The facility failed to ensure Resident #289's nails were cleaned and trimmed on 04/10/25. The facility failed to ensure Resident #289's facial hair was shaved on 04/10/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #60, Resident #32, and Resident #179) reviewed for infection control. 1. The facility failed to ensure CNA D performed hand hygiene during incontinence care for Resident #60 on 04/08/25. 2. The facility failed to ensure LVN E sanitized the glucometer before and after with an EPA approved germicide after performing a FSBS on Resident #32 on 04/08/25. 3. The facility failed to ensure LVN J performed hand hygiene after obtaining a FSBS for Resident #179 on 04/08/25. 4. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 for one of three residents (Resident #32) reviewed for catheter and incontinence care. The facility failed to ensure CNA D and Restorative Aide I maintained the foley catheter drainage bag below Resident #32's bladder while they transferred the resident with a mechanical lift on 04/09/25. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for two of three (Resident #32, and Resident #289) reviewed for respiratory care. 1. The facility failed to ensure LVN E performed hand hygiene during tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care and failed to maintain sterile technique during tracheostomy care for Resident # 32 on 04/09/25. 2. The facility failed to obtain Physician orders for Resident #289's continuous oxygen with the number of liters to administer. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for one of nine (Resident #64) residents reviewed for pharmacy services. The facility failed to ensure facility staff re-ordered medications in a timely manner for Resident #64 which resulted in a missed dose of levothyroxine 50 mcg (used to treat low thyroid) on 04/09/25. The facility failed to keep medications secure when LVN H borrowed a medication from another resident to administer to Resident # 64. This failure could place residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 (Hall E) medication carts reviewed for medication storage. The facility failed to ensure LVN H kept medications secured and the E Hall medication cart locked and/or secured. LVN H failed to ensure medication pill was not loose on the E-Hall medication cart. This failure could place residents at risk of gaining access to unlocked medications that were not prescribed to them.
November 8, 2024Complaint inspection · 1 citation
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 members of the facility staff were able to demonstrate competency in the provision of skills and techniques necessary to provide quality care as outlined by the comprehensive care plan for 1 of 1 residents reviewed for plans of care. (Resident #1). The facility failed to ensure the staff providing activities of daily living (ADL) care were knowledgeable and competent on the facility's transfer and repositioning policy; Certified Nurse Aide (CNA) A grabbed Resident #1's neck to reposition him in bed, which resulted in the facial grimacing. The noncompliance was identified as past noncompliance (PNC). The facility identified the noncompliance on 9/5/2024 and corrected the noncompliance on 9/9/2024 before the investigation began on 11/7/2024. [...]
May 2, 2024Complaint inspection · 2 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure grease trap in oven was not free of grease buildup. 2. The facility failed to ensure the sides of the stove were clean from food residue and grease build up. These failures could place residents at risk for food contamination and food-borne illness.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure that Resident #1's fall mat was placed on both sides of his bed as noted in his care plan. This failure could put residents at increased risk for accidents and injury.
March 7, 2024Standard inspection, Complaint inspection · 3 citations
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an ongoing resident centered activities program that incorporated and met the resident's interests, hobbies, and cultural preferences which was integral to maintaining and improving a resident's physical, mental, psychosocial well-being, and independence for 4 (Resident #1, Resident #14, Resident #17, and Resident #29) of 5 residents reviewed for resident rights and activities. The facility failed to ensure the activities program was resident centered and reflected resident's interests and preferences for Residents #1, #14, #17, and #29. This deficient practice could place residents at risk of negative psychosocial outcomes, negative physical and mental outcomes by not creating opportunities for each resident to have a meaningful life and to be engaged with their community.
- 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 review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to label and date food stored in the reach-in refrigerator that should no longer be consumed. 2. The facility failed to label and date food in the dry storage. 3. The facility failed to date food stored in the walk-in refrigerator that should no longer be consumed. 4. The facility failed to store food in a sanitary manner in the walk-in refrigerator. 5. The facility failed to date food in the general storage area. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding for 1 of 3 residents (Resident #40) reviewed for reviewed for feeding tubes. The facility failed to ensure Resident #40's feeding bag was labeled and dated. This failure could result in complications of enteral feedings such as receiving the wrong feeding or outdated feeding.
Fire safety inspections
8 fire safety citations on file: 3 on June 18, 2026, 4 on April 24, 2025, 1 on March 7, 2024.
Every fire safety citation8 citations
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 18, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 18, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 18, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 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 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · April 24, 2025 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 7, 2024 · Corrected (the home has a date of correction)