1339 Eastwood Dr., Seguin, TX 78155 · Guadalupe County · (830) 379-3900
115 certified beds, about 70 residents a day · Government - Hospital district · Medicare and Medicaid since 2011
CMS Care Compare ratings, data as of September 1, 2026 · CCN 676274 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 13, 2026, inspectors cited 8 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 49 health citations since October 2023, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 2 fines totaling $18,225 in the last three years; the largest was $9,246, and the latest is dated October 24, 2025.
Nurses and nurse aides worked 3.39 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.16 of those hours.
CMS links it to The Ensign Group, an affiliated group of 344 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 49 health citations on file.
Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 24 residents ( residents #7, #13 and #21) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure a care plan was developed to address Resident #7's oxygen therapy. 2. The facility failed to ensure a care plan was developed to address Resident #13's anticoagulant. 3. The facility failed to ensure a care plan was developed to address Resident #21's need to have her apical pulse checked. [...]
Inspectors wroteBased on observations and interviews, the facility failed to ensure the menus were followed and documented any substitutions made to the menus for 1 of 1 menus reviewed for accuracy. The facility failed to follow the recipe requirements to make enough food to be served on the menu. This failure could place residents at risk for inadequate nutritional needs.
Inspectors wroteBased on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 15 staff (LVN I) reviewed for Administration. The facility failed to ensure LVN I's nursing license was current since [DATE]. This failure could place residents at risk of not receiving their care from a licensed nurse when required.
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 disease and infections for 3 of 7 residents (Residents #3, #33, and #69) reviewed for infection control. 1. The facility failed to ensure Resident #3 was on contact precautions per CDC guidelines and facility policy. 2. The facility failed to ensure the DON put on a gown when he performed wound care for Resident #33 who was on EBP. 3. The facility failed to change gloves during incontinent care for Resident #69. 4. The facility failed to ensure the residents clean clothing was covered when delivering to the residents on 2/11/26. These failures could place residents at risk of cross contamination and infections.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents had the right to reside and received in the facility with a reasonable accommodation of resident needs and preferences for 1 of 6 residents (Resident #6) reviewed for call lights. The facility failed to ensure Resident #6's call light was in reach. This failure could place residents at risk for falls, delay of care, and decreased the ability of independent functioning, dignity, and well-being. [...]
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure comprehensive care plans were developed within seven days of the completion of the comprehensive assessment and were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 resident of 24 residents (Resident #62) reviewed for care plans. The facility failed to ensure Resident #62's comprehensive person-centered care plan was revised after the quarterly MDS assessment to reflect she was incontinent of bowel and bladder. This failure could place residents at risk of a lack of assistance with care.
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 1 of 1 kitchen, in that: A box in the freezer with a bag of bread sticks were open to air. Four plastic seasoning bottles on a shelf in the kitchen area were opened, and seasoning was on the holes that dispense the seasoning, preventing them from closing. A sugar container had a scoop on the inside of the container. These failures could place residents at risk for food borne illness.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. The facility failed to close the door on the dumpster. This failure could place the residents at risk of pest and rodents that could cause contamination of foods stored in the kitchen, infection and illness.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure 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 were developed and implemented within 48 hours of a resident's admission and included the minimum healthcare information necessary to properly care for residents, for 1 of 3 residents, (Resident #2), reviewed for comprehensive resident centered care plan. The facility failed to develop interventions for Resident #2's intravenous access when he was admitted on [DATE]. This failure could place residents at risk for harm by not having interventions in place to support their healthcare needs.
Inspectors wroteBased on interviews and record reviews 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 the residents' choices, for 1 of 3 residents (Resident #2) reviewed for providing care without a physician's orders. The facility failed to recognize Resident #2 had received medications and fluids through an intravenous access without orders for the intravenous access. This failure could place residents at risk for harm by receiving care without physician's orders.
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 1 of 6 residents (Resident #1) reviewed for drug administration. Resident #1 was administered 5 tablets of Carbidopa-Levodopa 25-100mg on 10/21/2025 at noon. The physician order was Carbidopa-Levodopa 25-100mg give 1.5 tablets at 11 a.m. Resident #1 was transferred to the hospital on [DATE] for altered mental status. The noncompliance was identified as PNC. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for not receiving a therapeutic effect or being over-medicated.
Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident's responsible party, consistent with his or her authority, when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 6 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party when Resident #1 had a medication error, change in condition, and was transferred to the hospital on [DATE]. This failure could place residents at risk of a decreased quality of life or hospitalization resulting in a decline in psychosocial or physical health.
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 1 of 1 kitchen observed for kitchen sanitation. 1. The facility failed to ensure 4 pitchers of beverages were covered and dated when prepared. 2. The facility failed to ensure box of powder sugar was dated with open date. 3. The facility failed to ensure opened bag of spaghetti was properly sealed with an opened date. 4. The facility failed to ensure opened bag of elbow noodles was dated with an opened date. 5. The facility failed to ensure food temperatures were taken in a sanitary fashion. 6. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 11 residents (Resident #6, Resident #22 and Resident #62) reviewed for care plans. 1. The facility failed to ensure Resident #6's care plan reflected his receiving hospice services and did not have an active care plan. 2. The facility failed to ensure Resident #22's care plan reflected his pain management. 3. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 4 of 19 residents (Resident #4, Resident #25, Resident #30 and Resident #39) reviewed for care plan revisions. 1. The facility failed to ensure Resident #4's care plan was revised quarterly. 2. The facility failed to ensure Resident #25 care plan was revised after Significant Change in condition and when resident returned from the hospital. 3. The facility failed to ensure Resident #30's care plan was revised or reviewed after the quarterly MDS was completed on 09/25/2024. 4. [...]
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure resident received food prepared in a from designed to meet individual needs for 1 of 2 meals, reviewed for nutrition services. The facility failed to ensure the breakfast meal served on 12/03/2024 had the appropriate consistency for the meat serving for the puree textured diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss.
Inspectors wroteBased on interview and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 10 of 19 staff (CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director) reviewed for training, in that: The facility failed to ensure that CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director had completed their mandatory QAPI annual training. This failure could place residents at risk for care by staff who had been insufficiently trained while working in the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure compliance and ethics training was completed for 10 of 19 employees (CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director) reviewed for orientation training. The facility failed to ensure that CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director had completed their mandatory ethics training. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 19 residents (Residents #34) reviewed for accommodation of needs. The facility failed to ensure Resident #34's call light was within reach while he was positioned in her wheelchair. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 19 residents (Residents #34) whose assessments were reviewed, in that: The facility failed to ensure Resident #34's quarterly MDS, dated [DATE], correctly assessed the resident's functional limitation in range of motion status as evidence by coding No impairment to upper extremity. However, Resident #34 had impairment regarding function limitation in range of motion to his left arm. These failures could place residents at-risk for inadequate care and services.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 3 (Resident #30) reviewed for respiratory care. Resident #30's physician order indicated the resident had oxygen via nasal cannular on 2 liter per minute, but the resident was observed on 12/01/2024 at 3:10 p.m. receiving oxygen 2.5 liter per minutes and on 12/03/2024 at 11:30 p.m. receiving 3.5 liter per minutes. This failure could affect residents with oxygen therapy and could lead to care as ordered by the physician.
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 1 of 2 medication room (Recovery Medication Room) and 1 of 4 medication carts (Recovery Nursing Cart) reviewed for pharmacy services. 1. There was one bottle of medication (Ocular Vitamins for eye) expired on 09/2024 found inside the Recovery medication room on 12/04/2024. 2. There was one gel of medication (antimicrobial skin and wound gel hospital and professional use only) expired on 08/01/2024 found inside the Recovery nursing cart on 12/04/2024. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.
Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 1 of 5 (Resident #30) reviewed for unnecessary medications. The facility failed to discontinue Resident #30's Melatonin 5 mg for sleep after the resident's primary care physician agreed on 09/18/2024 to the pharmacist's recommendation on 08/21/2024, which was for Resident #30, melatonin 5 mg due for gradual dose reduction, consider as needed for 14 days, then discontinue. This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 4 nursing carts (treatment cart) reviewed for storage, in that: The facility failed to ensure the Treatment Cart was locked when left unattended. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the hospice services met professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services for 1 of 3 residents (Resident #27) reviewed for administration: There were no hospice nursing notes, records of visits or care available for Resident #27 at the facility. This failure could place residents receiving hospice services at risk of not receiving their needed services and care, and a decreased continuity of care between facility staff and hospice staff.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 residents (Residents #48 and #59) of 19 residents reviewed for infection control. 1. The facility failed to Resident #48's suction tube Yankauer (oral suction tool used in medical procedure) to be covered in a plastic bag when it was not used on 12/01/2024. The Yankauer was connected to the suction machine and hanging without a plastic bag. 2. When CNA-H was providing incontinence care to Resident #59, the CNA-H had multiple pass with one wipe and touched new and clean brief with old and dirty gloves on 12/03/2024 at 2:07 PM. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys (the Medication Cart) for 1 medication cart out of 3 medication cart's reviewed for medication storage. The facility failed to ensure medications were secured on medication cart # 2 The non-compliance was identified as past non-compliance. The noncompliance began on 10/3/2024 and ended on 10/5/23. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents at risk of medication misuse or drug diversion.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's right to be free from misappropriation of resident property for 1 of 3 residents (Resident #1), reviewed for drug diversion. Resident #1's scheduled narcotic pain medication, 81 tablets (2 pharmacy cards) went missing from the medication cart and was never found. This failure could place residents at risk of misappropriation, and could result in increased pain, and poor 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 1 of 3 residents (Resident #1) reviewed for pharmacy services. Resident #1's narcotic pain medication was not counted as required, the keys to the medication cart left unsecured, and resulted in 81 tablets being drug diverted and the resident missed 4 doses of his scheduled pain medication . This failure could place residents at risk of misappropriation by drug diversion, and could result in increased pain, and poor quality of life.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed who required having leg rests and foot pedals on their wheel chairs for quality of care. The facility failed to ensure Resident #1 had her leg rests and foot pedals on her wheelchair when she went to an appointment on 04/17/2024 and her unsupported right foot slid off from her other foot which was supporting it and was caught under the moving wheelchair pushed by the Maintenance Director and resulted in a fractured femur (thigh and upper hind limb bone, longest strongest bone in the body) . [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Residents #1, #2, and #3) out of 3 residents reviewed who required wheelchair leg rests and foot pedals for comprehensive resident centered care plans. 1. Resident #1's comprehensive care plan (undated) did not reflect she partially depended on staff to wheel her in a wheelchair for locomotion and she needed the leg rests and foot pedals for support. 2. Resident #2's comprehensive care plan inaccurately reflected she was ambulatory and mobilized in her wheelchair. [...]
Inspectors wroteBased on observation, interviews and record reviews, 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 serious bodily injury for 1 (Resident #1) of 3 resident reviewed who required having their wheelchairs for transport for freedom from abuse, neglect, and exploitation. The facility failed to ensure the Maintenance Director, who drove Resident #1 to an appointment, reported that Resident #1 had an incident with her right foot and leg dropping down under the moving wheelchair and getting caught as she was assisted out of the van, until the next morning. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to assure that residents received a therapeutic diet as prescribed by the physician for 1 of 5 residents (Resident #4) reviewed in that: Resident #4 was on a regular diet with no fried or high fat foods and was given fried okra during meal service which did not meet his dietary needs. This failure could affect residents who are prescribed a no fried or high fat foods diet and could result in heart disease or stroke.
Inspectors wroteBased on observation, interview and record review the facility failed to provide special eating equipment for 1 of 5 residents (Resident #1) reviewed for assistive devices in that: Resident #1 was not provided with a plate guard (helps prevent food from accidently being pushed off the plate while eating) during meal service to minimize food spillage and help the resident remain as independent as possible. This deficient practice could affect residents who required assistive devices for meals and could result in poor nutritional intake.
Inspectors wroteBased on observation, interview, and record review of residents' rooms revealed the facility failed to equip for adequate nursing care, comfort, and privacy of residents, 8 out of 8 Rooms (110, 212, 210, 209, 208, 408, 514, and 512) reviewed for equipped for adequate nursing care, in that: rooms [ROOM NUMBERS], were used as storage rooms. Rooms 210, 209, 208, 408, and 514, AC blower was not working. room [ROOM NUMBER], the AC unit was not working. These failures could result in rooms not being available for an influx of new residents in the event of a local or national emergency.
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 1 of 1 kitchen reviewed, in that: 1. The top of the dish machine was soiled with a sand-like substance. 2. The door of the freezer near the dish room was soiled. 3. Three containers of ground meat wrapped in plastic were thawing on a countertop. 4. Powdered milk container in the pantry was labeled milk and also labeled rice. 5. The containers of loose sugar and flour had lids that were not secure. 6. The large walk-in refrigerator had debris in the floor and contained: -two thermometers with different temperature readings -a container of heads of lettuce with multiple brown spots. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protect and promoted the rights of the resident for 2 of 15 residents (Resident #7 and #64) reviewed for dignity, in that: Residents #7, and #64 urinary drainage bags were not covered or in a dignity bag for privacy. This deficient practice could place residents at risk of embarrassment, lack of privacy, and loss of dignity.
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 for 1 (Hall 400) 8 halls reviewed for accident hazards, in that: A container of liquid disinfectant was stored in an unlocked room in Hall 400. This deficient practice could place residents at risk of harm by coming into contact with hazardous materials.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was provided necessary respiratory care consistent with professional standards of practice for 3 of 6 residents (Residents #34, and #11, and #30) reviewed for respiratory care in that: 1. Resident #34's nebulizer tubing was outdated, and on the floor. The resident's nebulizer mask was disconnected from the tubing and on the floor on 4 of 4 days (10/24/23, 10/25/23, 10/26/23. and 10/27/23) of observations. 2. Resident #11's humidification water bottle was not connected. 3. Resident # 30 did not have physician orders for oxygen and oxygen was in use. This failure could place residents at risk of delays in receiving necessary respiratory care, and illness.
Inspectors wroteBased on observation, interview and record review the facility failed to promote and facilitate the residents right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care for 1 of 4 residents (Resident #6) reviewed for self-determination in that: Resident #6 was taken to his room during a behavior and put in bed despite the resident protesting by yelling and hitting staff during transfer. This failure could place residents at risk of feeling like they have no rights, no choice, and no control, and could result in increased aggression, anger, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #16) of 18 residents reviewed for advance directives, in that: Resident #16 was able to make her wishes known and her OOH-DNR was executed by her daughter. This deficient practice put residents at risk of not having their rights honored and of receiving CPR against their will.
Inspectors wroteBased on interview and record review, the facility failed to complete an assessment within 14 days after the resident experienced a significant change in status for 1 (Resident #53) of 18 residents reviewed for resident assessment, in that: A feeding tube was placed for Resident #53 and the facility failed to re-assess the resident. This deficient practice could lead to improper care and diminished quality of life for residents whose needs are not fully assessed.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident for 1 (Resident #68) of 18 residents reviewed for comprehensive care plans, in that: Resident # 68's therapeutic diet was not listed on his care plan. This deficient practice could result in resident's receiving improper care and improper diets due to a lack of communication.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 (Resident #53) of 4 residents with pressure ulcers reviewed, in that: Resident #53 did not receive treatment for her pressure ulcer for 10 days and the pressure ulcer worsened. This deficient practice could place residents with pressure ulcers at risk of pain and diminished quality of life due to wounds.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections for 1 of 15 residents (Resident #7) who were reviewed for indwelling urinary catheter care, in that; a. Residents # 7's Condom catheter was not removed on 10/25/23 and 10/26/23 as per physician orders These deficient practices could affect residents with indwelling urinary catheters and place them at risk of urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate was not 5% or greater. The facility had a medication error rate of 32%, based on 7 errors out of 25 opportunities, which involved 2 of 5 residents (Resident #40, Resident # 13) and 1 of 4 staff (CMA D) reviewed for medication administration. The facility failed to ensure CMA D administered medications according to the physician's orders and per professional standards which resulted in a 32% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions.
Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident # 7) reviewed for accuracy of medical records in that: Resident # 7's order to remove condom cathater in the [NAME] was not done and treatment record signed . This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.
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 1 of 1 kitchen, in that: 1. DA A had facial hair and did not wear a facial hair restraint in the kitchen while portioning food for the lunch meal. 2. DA B did not change gloves or wash her hands after touching a cellular phone while preparing food in the kitchen. 3. DA B wore jewelry on her arm while engaged in food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 4 of five residents (Residents #1, #2, #3 and #4) reviewed for food meeting residents' needs, in that: Cook E did not puree ground beef to a pudding or mashed potato consistency as required for food served to residents who received a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss.
15 fire safety citations on file: 7 on February 13, 2026, 8 on December 4, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| October 24, 2025 | Fine | $9,246 |
| May 1, 2024 | Fine | $8,979 |
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) | 3.39 | 3.39 | 3.86 |
| Registered nurses | 0.16 | 0.43 | 0.69 |
| All nursing staff on weekends | 2.94 | 2.98 | 3.42 |
| Nurse aides | 2.11 | ||
| Licensed practical nurses | 1.12 | ||
| 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 | not reported |
CMS expects 3.81 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 3.58 on weekdays and 2.94 on weekends, 18% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.29 in April to June 2025 to 3.39 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 | 3.39 | 0.16 | 3.58 | 2.94 | 2.8% | 2 of 90 | 70 |
| Oct to Dec 2025 | 3.37 | 0.23 | 3.57 | 2.86 | 0.9% | 0 of 92 | 66 |
| Jul to Sep 2025 | 3.20 | 0.26 | 3.40 | 2.72 | 1.8% | 0 of 92 | 72 |
| Apr to Jun 2025 | 3.29 | 0.34 | 3.48 | 2.82 | 1.5% | 0 of 91 | 64 |
| 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 | 7.4 | 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 | 0.0 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.9 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.8 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 12.1 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.8 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.7 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 33.8 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 14.6 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.9 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.9 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for River Bend Healthcare's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (50.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
50.5% 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. 45 eligible stays.
9.2% 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. 70 eligible stays.
8.1% this home
No different from the national rate
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. 42 eligible stays.
50.0% this home
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. 22 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. 43 residents counted.
1.6% 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. 43 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. 14 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: WEST COKE COUNTY HOSPITAL DISTRICT. CMS links this home to The Ensign Group, a group of 344 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| McGuire, Wesley | Corporate officer | Individual | 11/01/2025 | |
| River Bend Opco LLC | Operational/managerial control | Organization | 11/01/2025 | |
| Jass, John | Operational/managerial control | Individual | 11/02/2025 | |
| Martin, Christopher | Operational/managerial control | Individual | 11/01/2025 | |
| Kilgore, Joshua | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 11/03/2025 | |
| Rankin, Derek | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 11/01/2025 | |
| Rye, Robert | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 11/03/2025 | |
| Stein, James | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 11/03/2025 | |
| Stein, Paul | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 11/03/2025 | |
| Krs Seguin, LLC | Adp of the SNF | Organization | 11/01/2025 | |
| Ktfw-Ok, LLC | Adp of the SNF | Organization | 11/01/2025 | |
| Sr Properties of Tx SNF LLC | Adp of the SNF | Organization | 11/01/2025 | |
| Jass, John | Adp of the SNF | Individual | 11/01/2025 | |
| Lockhart, Christopher | Adp of the SNF | Individual | 11/01/2025 |
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.
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.