940 York Drive, Desoto, TX 75115 · Dallas County · (972) 572-6200
242 certified beds, about 213 residents a day · For profit - Corporation · Medicare and Medicaid since 1998
CMS Care Compare ratings, data as of September 1, 2026 · CCN 675756 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on March 10, 2026, inspectors cited 15 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 84 health citations since October 2023, 9 were rated as actual harm or immediate jeopardy to residents (9 immediate jeopardy).
CMS lists 9 fines totaling $150,370 in the last three years; the largest was $23,371, and the latest is dated April 27, 2026.
Nurses and nurse aides worked 2.81 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.17 of those hours.
41.5% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to Dallas County Hospital District, an affiliated group of 5 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 84 health citations on file.
Inspectors wroteBased on observation, interview and record review the facility failed to develop the comprehensive care plan within seven days of the completion of the comprehensive assessment and review and revise the care plan after each assessment for 2 of 3 residents (Resident #1 and Resident #2) reviewed for comprehensive care plans in that: The facility failed to ensure Resident #1's care plan, dated 05/21/26, was revised to address his recent incident of aggression toward another resident on 07/15/2026. The facility failed to ensure Resident #2's care plan, dated 07/03/26, was revised after completion of the comprehensive assessment to include goals, preferences and care needs of the resident. This failure placed residents at risk of not receiving timely and appropriate individualized care to prevent harm.
Inspectors wroteBased on observations, interviews, 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 3 of 7 residents (Residents #3, #4, and #5) reviewed for accommodation of needs. The facility failed to ensure Resident #3, #4, and #5's call lights were placed within reach on 07/10/26. These failures could place residents at risk of injuries and unmet needs.
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 the necessary services to maintain good grooming, and personal hygiene for 1 (Resident #2) of 5 residents reviewed for ADL care. The facility failed to ensure Residents #2 received timely incontinent care on 07/10/26 which caused the resident to remain in urine soaked clothing. This failure had the potential to affect residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #3) reviewed for medication administration. The facility failed to ensure Resident #3 was administered all of her medications when the medication Ropinirole was found on the floor of her room on 07/10/26. This failure placed residents at risk of not receiving medications as prescribed, decreased therapeutic effects of the medications, risk for drug diversion, delay in medication administration and worsening of their medical conditions.
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 2 of 5 residents (Resident #1 and #2) reviewed for infection control.1. The facility failed to ensure the Wound Care Nurse performed hand hygiene and changed gloves during wound care for Resident #1.2. CNA A failed to perform hand hygiene while providing incontinence care to Resident #2. This failure could place residents at risk for cross-contamination and infection.
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 1 of 4 residents (Resident #1) reviewed for ADL care. The facility failed to provide Resident #1 with incontinence care every two hours and as neededThis failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life.
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 4 residents (Resident #1) reviewed for infection control. CNA A and CNA B failed to perform hand hygiene while providing incontinence care to Resident #1. This failure could place residents her at risk for cross-contamination.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent avoidable accidents for one (Resident #1) of eleven residents reviewed for supervision. The facility failed to ensure Resident #1, who resided on the facility's secured unit, received adequate supervision to prevent him from eloping on two separate occasions. On 04/20/26, Resident #1 eloped from the facility at 2:00 a.m. and was found 2.5 hours later by law enforcement approximately 2 miles away from the facility. On 04/24/26, Resident #1 eloped from the facility at 1:30 a.m. and was found on 04/27/26 at a local hospital where he was being treated for chest pain. An Immediate Jeopardy (IJ) was identified on 04/24/26 at 12:02 p.m. and an IJ Template was provided to the Interim Administrator at 12:45 PM. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure that the discharge summary included an accurate and current description of the clinical status of the resident and sufficiently detailed individualized care instructions to ensure that care was coordinated and the resident transitioned safely from one setting to another for one (Resident #2) of three residents reviewed for discharge process. The facility failed to ensure that Resident #2's discharge summary included appropriate clinical information to ensure that the resident received continuous and coordinated care after she discharged to the community AMA (against medical advice) on 04/06/26. This failure could place residents at risk of not receiving ongoing person-centered care, which could lead to worsening of condition or serious harm.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for 1 of 5 residents (Resident #1) reviewed for change in condition. LVN L failed to immediately consult with Resident #1's physician and failed to notify the resident's family when Resident #1 fell hard against a rail in the hallway hitting his face/head and torso, which resulted in immediate bleeding to the resident's cheek on 03/22/26 at 7:30 AM. The resident's family noticed a change in the resident's mental status at 5:00 PM and noted a bloody bandage on the resident's face. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 8 residents (Resident #1) reviewed for quality of care. LVN L failed to complete an immediate, comprehensive post-fall assessment to include neurological checks after Resident #1 had a fall when the resident swung hard towards LVN L in an attempt to hit him on 03/22/2026 at 7:30 AM, which resulted in the resident losing his balance and hitting his face/head and torso against a rail in the hallway. The resident had bleeding on his cheek which LVN L put a bandage on; however, LVN L did not notify the physician of the fall nor did he notify the resident's family. [...]
Inspectors wroteBased on observations, 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 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 1 of 1 resident (Resident #1) reviewed for reportable incidents of abuse and [...]
Inspectors wroteBased on interview and record review, the facility failed to have evidence allegations of neglect were thoroughly investigated and documented for 1 of 1 resident (Resident #1) reviewed for neglect. The Administrator failed to conduct a thorough investigation after being notified by the hospital on [DATE] that Resident #1 had sustained serious bodily injury after a fall on 03/22/2026 at the facility which LVN L had failed to report to the Administrator and had failed to notify the physician and the resident's family member. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 2 of 10 residents (Residents #169 and #195) reviewed for resident rights. The facility failed to provide privacy covers for the urinary collection bags for Residents #169 and #195. This failure could place residents at risk of a lessened sense of self-worth.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 33 of 35 and resident's admission Records and 2 of 10 (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for personal privacy. The facility administration failed to protect the residents' privacy by having private information of residents in a binder in the front lobby of the facility. The facility failed to ensure resident rooms had full visual privacy, Rooms #114 did not have a privacy curtain and room [ROOM NUMBER] did not have window blinds. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to lack of privacy during care.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a residents who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 35 residents (Residents #15 and #69) reviewed for ADLs. 1. The facility failed to ensure Resident #15's fingernails were routinely trimmed. 2. The facility failed to ensure Resident #69's fingernails were trimmed routinely, and her facial hair was shaved regularly. These failures could place residents at risk for a decreased sense of self-worth, as well as potential skin injury.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 2 of 2 kitchens (North Kitchen and South Kitchen) reviewed for kitchen sanitation. 1. The facility failed to ensure freezers in the North and South Kitchen were functioning to prevent thawing and to keep food solid. Food items that had been thawed and were soft to touch, and kept between 40 and 50 degrees Fahrenheit, were not discarded.2. The facility failed to correctly thaw beef patty fritters served for lunch on 03/09/26 from the South Kitchen.3. The facility failed to label, date, and discard items in the reach in refrigerator, and label and date items in the dry storage in the South Kitchen.4. [...]
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition by failing to maintain freezers in two of two kitchens (North and South Kitchen) and failed to maintain 1 of 13 (Resident #147) bed in safe operating condition.1. The facility failed to ensure freezers in the North and South Kitchens were functioning to prevent thawing and to keep food solid. Food items that had been thawed and were soft to touch and kept between 40- and 50-degrees Fahrenheit, were not discarded.2. The facility failed ensure the Resident #147's bed was in proper working condition. These failures could place residents at risk of foodborne illness and at risk for injury and a decreased quality of life.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure rooms were equipped to assure full visual privacy for each resident for 3 (Rooms # 115, #116, #119) of 18 rooms reviewed for visual privacy. The facility failed to ensure resident rooms had full visual privacy, Rooms # 115, #116, and #119, did not have a privacy curtain. This failure could place residents at risk of being exposed during cares or when changing clothes.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest for 1 of 5 residents (Resident #232), 1 of 2 kitchens (North Kitchen), and 1 of 2 halls reviewed for pest control. The facility failed to ensure the facility was free of gnats in Resident #232 room, North kitchen and 700 Hall. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to self-administer medications if the interdisciplinary team determined that this practice was clinically appropriate for 2 of 2 residents (Resident #102 and Resident #232) reviewed for resident rights.1. The facility's interdisciplinary team failed to ensure Resident #102 was clinically appropriate to self-administer Atrovent 17mcg hfa inhaler that was with the resident in the TV room.2. The facility failed to ensure Resident #232's eye drops and arthritis pain cream, located at his bedside, was clinically appropriate to self-administer medications. These failures could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable and homelike environment, including but not limited to Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 35 residents (Residents #147) reviewed for environmental conditions. The facility failed to ensure Resident #147's ceiling plaster was not hanging from the ceiling. This failure could place residents at risk for injury and a decreased quality of life.
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, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 of 16 residents (Resident #54, #36) reviewed for care plans.1. The facility failed to develop a care plan for Resident #54's use of a feeding tube for nutrition or his noncompliance with physician orders which indicated Resident #54 to have nothing to eat or drink by mouth.2. The facility failed to ensure Resident #36's care plan addressed antibiotic treatment via CVC line (used to deliver medications and other treatments directly to the large central veins near heart). [...]
Inspectors wroteBased on observation, interview 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 including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 2 of 13 residents (Resident #54 and #229) reviewed for feeding tubes .1. The facility failed to ensure Resident #54's formula and water bag was properly labeled with the resident name, name of formula, feeding rate, date, time his formula and water was administered along with the nurse's initials.2. The facility failed to follow physician's orders of providing Resident #229 with his 22-hours of feeding intake and failed to ensure the formula bag was changed on 03/08/26. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 2 residents (Resident #36 and Resident #227) reviewed for intravenous medication. 1. The facility failed to ensure Resident #36, and Resident #227's intravenous medication bag and tubing were labeled with the date, time, and initials.2. The facility failed to change and maintain the integrity of Resident #36's CVC line (used to deliver medications and other treatments directly to the large central veins near heart) dressing per professional standards.3. [...]
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 4 medication carts (Halls 600 B nurse medication cart), 1 of 2 medication rooms (600 Hall medication room), and 1 of 5 residents (Resident #54) reviewed for labeling of drugs and biologicals.1. The facility failed to ensure expired medications were removed from the Hall 600 B medication cart and Hall 600 medication room.2. The facility failed to ensure LVN Q administered all morning medication to Resident #54. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.
Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was free of any significant medication errors for 1 of 7 residents (Resident #54) reviewed for medications. The facility failed to ensure LVN Q administered Resident #54 with his morning medications resulting in significant medication errors. These failures placed residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician, which could result in exacerbation of conditions.
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 2 of 7 residents (Residents #107 and #125) reviewed for infection control. The facility failed to ensure MA NN disinfected the blood pressure cuff between blood pressure checks for Residents #107 and #125 during medication administration. These failures placed residents at risk of cross contamination and the spread of infection.
Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure residents remained free of accident hazards as possible for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to provide Resident #1, who had dementia, with adequate supervision on 01/29/26 when the resident was left unattended and unsupervised on the facility's van from approximately 4:30 PM until 9:00 PM when temperatures were in the 30 degree Fahrenheit range. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 01/29/26 and ended on 02/02/26. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk of death, related to cold or heat exposure, discomfort, pain, and anxiety. [...]
Inspectors wroteBased on observations, interviews, and records 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 3 (Residents #2, #3, and #4) of 3 residents reviewed for pressure ulcers.1. The facility failed to provide wound care to Resident#2's Unstageable wound of the left heel, on 01/17/2026 and 01/18/2026.1a. The facility failed to provide wound care to Resident #2's stage 4 pressure wound of the left medial first toe and the left fourth toe on 01/17/2026, 01/23/2026, 01/24/2026, 01/30/2025 and 01/31/2026. 1b. [...]
Inspectors wroteBased on record reviews and interviews, the facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment immediately, but no later than 2 hours after the allegation is made for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to notify HHSC when Resident #1 was discovered to have been left in a transport van for several hours in the cold. This failure could place residents at risk of neglectful behavior not being investigated. Findings Include:Record review Resident #1's quarterly MDS assessment, dated 01/29/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney failure requiring dialysis, dementia, and paranoid schizophrenia. Resident #1's BIMS score was 6, indicating he had severe cognitive impairment. His Behaviors assessment did not indicate he did not wander. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure a mechanical lift was used to transfer Resident #1 from her bed to the wheelchair on 12/23/25 when they were getting the resident up to go to the dialysis center. During the transfer, the resident reported that her leg got twisted which caused her severe pain. The resident was then sent to the dialysis center where she complained of severe pain and was transferred to the hospital where she was diagnosed with a comminuted fracture (a severe injury where a bone breaks into three or more fragments, typically caused by high-impact trauma), which required surgery. An IJ was identified on 02/12/26. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for one of two incidents reviewed for reporting. The facility failed to report an allegation of neglect when Resident #1 alleged that her leg had been broken during a transfer from her bed to the wheelchair on 12/23/25 due to the facility staff not using a mechanical lift. This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, exploitation, and mistreatment, including injuries of unknown source were thoroughly investigated for one (Resident #1) of 3 residents reviewed for neglect. The facility failed to thoroughly investigate an allegation of neglect when Resident #1 alleged that she sustained a fractured left femur (the bone of the thigh) during a transfer in which staff did not use a mechanical lift as care planned. This failure could place residents at risk of abuse and neglect.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 2 of 5 residents (Residents #5 and #6) reviewed for ADL care. The facility failed to ensure Residents #5 and #6 were provided with timely incontinence care. 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.
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 5 residents (Residents #5 and #6) observed for infection control. CNA D failed to perform hand hygiene and change gloves while providing Residents #5 and #6 with incontinence care. This failure could affect the residents by placing them at risk for worsening conditions and cross-contamination.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #1. This failure could place residents at risk of not having complete records after permanent discharge from the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 6 residents (Resident #6 and Resident #8) reviewed for abuse. 1. The facility failed to ensure Resident #8 had the right to be free from abuse on 03/01/25 when Resident #9 hit him with a ruler 2-3 times, as the argument escalated further, Resident #9 then stabbed Resident #8 with a pen which resulted in scratches on his abdomen and the back of his neck. Resident #8 was sent to the hospital for further evaluation. 2. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 pushed her on 03/09/25 while on the secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury. The noncompliance was identified as PNC. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 who had a history of wandering and exit-seeking, was provided with adequate supervision to prevent her from eloping on 06/09/25. Resident #1 was found 5 minutes away from the facility by police and was transported to the hospital for evaluation due to the resident experiencing hallucinations and delusions. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 06/09/25 and ended on 06/10/25. The facility had corrected the noncompliance before the survey began. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 2 of 2 residents (Residents #3 and #4) reviewed for ADL care. The facility failed to provide incontinence care to Residents #3 and #4 every 2 hours and as needed. 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.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident 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 of 3 residents (Resident #2) reviewed for pressure ulcer treatment. The facility failed to ensure Resident #2 received wound care according to physician orders. This failure could place the resident at risk of worsening wounds.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #100) reviewed for enteral nutrition. The facility failed to follow Resident #100's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.
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 2 residents (Residents #3 and #4) observed for infection control. 1. CNA I, CNA JJ and CNA KK failed to perform hand hygiene while providing incontinence care to Resident #3 and #4. 2. The facility failed to ensure RN X performed hand hygiene and changed gloves during wound care for Resident #4. This failure could affect the residents by placing them at risk for worsening conditions and cross contamination.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for four (Residents #1, #2, #3 and #4) of four residents reviewed for physician services. The facility failed to ensure Residents #1, #2, #3 and #4 were seen by their attending physician at least once every 60 days. The attending physician's extender was completing all visits for the residents, not alternating visits with the physician. [...]
Inspectors wroteBased on interviews 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 one (Resident #3) of four residents reviewed for pharmacy services. The facility failed to administer Resident #3, who had a diagnosis of dementia, with her morning medications on 03/26/25 and 03/27/25. Both the medication aide and nurse acknowledged they were busy and did not attempt to give them to her again after one refusal. As a result, Resident #3 missed eight different medications both days, including blood pressure readings related to blood pressure medication, as well as two supplements. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident's drug regimen must be free from unnecessary drugs, without adequate indications for its use for two (Residents #1 and #2) of four residents reviewed for psychotropic medications. The facility failed to ensure Residents #1 and #2 were not prescribed Austedo (a prescription medicine used to treat involuntary movements in adults with tardive dyskinesia (movement disorder characterized by involuntary movements) or Huntington's disease (an illness that causes nerve cells in the brain to decay over time and affects a person's movement, thinking ability, mental health) without adequate indications for its use. The failure could affect residents by placing them at risk for possible adverse side effects, a decreased quality of life and continued use of possible unnecessary medications.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for one (Resident #1) five reviewed for resident call system, in that: Resident #1's call lights was on the floor and not within reach on 03/24/2025. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident has a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of five residents (Resident #1) reviewed for care plans. The facility failed to follow Resident #1's care plan intervention of lowering the bed and the use of half bedrails due to fall risk. This failure could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who were unable to carry out activities of daily living received the necessary services to maintain good nutrition for one of three residents (Resident #1) reviewed for ADLs in that: The facility failed to ensure Resident #1 was provided with feeding assistance. This failure could place residents at risk of not receiving care and services to meet their needs which could result in nutritional needs not being met and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #6) reviewed for abuse. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 punched and then pushed her on 02/05/25 located on a secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury. The noncompliance was identified as PNC. The IJ began on 02/05/25 and ended on 02/05/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for abuse.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of five residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the ADON from taking two morphine pills prescribed for Resident #1 on 02/24/25. This failure could place residents at risk of pain and failure to achieve therapeutic effects intended by the physician. The noncompliance was identified as past noncompliance that began on 02/24/25 and ended on 02/24/25. The facility had corrected the noncompliance before the surveyor entered. No Plan of Correction required.
Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents were free of any significant medication errors for one of six residents (Resident #2) reviewed for pharmacy services. The facility failed to administer Resident #2's cancer medication, Ibrance, as prescribed, which resulted in the resident missing four doses between 08/26/24 and 08/29/24. This failure could place residents at risk of not achieving the therapeutic effects intended by the physician.
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 the necessary services to maintain good personal hygiene for 3 of 8 residents (Residents #23, #55 and #81) reviewed for ADL care. 1. The facility failed to ensure Residents #23 and #55 received grooming assistance to remove unwanted facial hair. 2. The facility failed to ensure staff provided consistent showers/baths for Resident #81. These failures could place residents at risk of not receiving hygiene care which could cause skin breakdown, a loss of dignity and self-worth.
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 2 of 2 kitchens (North kitchen and South kitchen) reviewed for food and nutrition services. 1. The facility failed to ensure food items were labeled and dated with name of product, date opened, and use by date. 2. Nutrition Aide M failed to wear a beard guard while prepping drinks for the lunch meal on 12/10/24. 3. Nutrition Aide L failed to wear a beard guard while putting away clean dishes on 12/10/24. These failures could place residents at risk for food borne illness.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a right to be treated with respect and dignity for 1 of 3 residents (Resident #189) reviewed for dignity. The facility failed to ensure Resident #189's catheter urine collection bag had a privacy cover. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 35 residents (Resident #55) reviewed for call light access. The facility failed to ensure Resident #55 had access to her call light. This failure could place residents at risk of not being able to call for assistance when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 1 resident (Resident #133) reviewed for wound care. The facility failed to ensure the diabetic wound on Resident #133's left upper side second toe was covered with a dressing. This failure could place residents at risk of pain and lead to systemic infections causing harm for residents.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Residents #189) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #189's catheter urine collection bag was kept off the floor. This failure placed residents at risk of urinary tract infection.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of five resident (Resident #81) reviewed for nutrition. The facility failed to ensure Resident #81 maintained acceptable parameters of nutritional status and provide timely interventions as demonstrated by Resident #81 experiencing a 15.51% weight loss in 30 days from October to November. Resident #81 had not continued to lose weight from November to December, however. This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.
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 securely for 2 (Resident #177 and Resident #189) of 18 residents and for 1 (100 Back Hall cart) of 8 carts reviewed for secure medication storage. 1. RN-F failed to secure his medication cart. 2. Resident #177 had 1 new box of arthritis pain cream stored at the resident's bedside table not locked in a lock box or secured in the medication cart or medication room. 3. Resident #189 had a tube of arthritis pain cream, zinc oxide cream, and eye drops inside his nightstand table not locked in a lock box or secured in the mediation cart or mediation room. These failures could place residents at risk of accessing medications not prescribed for them, and at risk of overmedicating or adverse drug reactions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and served according to the resident's assessment, plan of care, and in a form designed to meet the resident's needs for 1 (lunch on 12/10/24) of 3 meals reviewed for resident's needs. The facility failed to follow Resident #29's physician's order for pureed consistency food and nectar thickened liquids for the lunch meal on 12/10/24. This failure could place residents at risk of decreased food intake, weight loss and an increased risk of aspiration.
Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area and to ensure call light cord was accessible for 1 of 35 residents (Resident #130) reviewed for call light access. The facility did not adequately equip Resident #130's room with a call light cord to allow the resident to call for assistance. This failure could place residents at risk of not being able to call for assistance when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and home-like environment for 1 of 5 residents (Resident #1) reviewed for environment. The facility failed to ensure Resident #1's bed was made in a timely manner after being sanitized, which prevent the resident from being able to lie in bed. These failures could place residents at risk of an unsafe or uncomfortable environment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Medication Cart #1) of three medication carts reviewed. MA B failed to ensure Medication Cart #1 was locked when unattended on 08/27/24. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse for 1 (Resident #11) of 6 residents reviewed for abuse. The facility failed to supervise and protect Resident #11 from Resident #12, who had a diagnosis of dementia with a behavioral disturbance and was acting out on auditory hallucinations to hit other residents. On 04/02/24, Resident #11 was found on the floor, crying with bloody nostrils, while Resident #12 was standing over her yelling in an aggressive manner. The noncompliance was identified as PNC. The IJ began on 03/27/24 and ended on 04/03/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for six (Residents #2, #3, #4 #5 #6 and #7) of six residents reviewed for safe clean homelike environment. 1. The facility failed to ensure Residents #2, and #3 did not have soiled briefs in the trash cans in their rooms. 2. The facility failed to ensure Residents #2, #4, and #5 had clean privacy curtains in their rooms. 3. The facility failed to ensure the ceiling vents Resident #5, #6 and #7's rooms were clean. These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 6 (Residents #1, #2, #8, #9, #10, #13 ) of 6 residents reviewed for ADL care. The facility failed to provide incontinence care to Residents #1, #2, #8, #9, #10, #13 every 2 hours and as needed. 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.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident 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 2 (Resident #2 and #5) of 2 residents reviewed for pressure ulcer treatment. The facility failed to ensure Resident #2 and #5 received wound care according to physician orders. This failure could place the resident at risk of worsening wounds.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 6 residents (Residents #1 and #2) reviewed for ADLs. The facility failed to ensure Resident #1 and Resident #2 received showers as scheduled for the month of December 2023, January 2024, and February 2024. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one of three residents (Resident #3) reviewed for oxygen. The facility failed to ensure Resident #3's oxygen concentrator and nasal cannula was dated, labeled, and changed on a weekly basis. The facility failed to ensure Resident #3's oxygen delivered as ordered by physician at 2 liters per minute. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection.
Inspectors wroteBased on interview and record review the facility failed to ensure the resident's representative was notified when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The RP/family was not notified when of Resident #1 who was not capable of making decisions was discovered with a new wound on 09/22/23 denying the RP/family the opportunity to participate in the resident's treatment options. This failure could place residents at risk of not having the RP/family aware, informed of and/or participating in treatment options.
Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for wound assessments. Resident #1's wound to the right finger was not assessed until four days after discovery on 10/26/23. This failure placed residents at risk for delays in treatment, developing infections and unidentified deterioration of their wounds.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to self-determination for 2 of 7 residents (Residents #55, and #173) reviewed for self-determination in that: 1. CNAs failed to change Resident #55's bed linen, leaving her with no bed sheets. 2. Dietary staff were rude in their interactions with Resident #173 when discussing her food choices. These failures could place residents at risk of decreased feelings of self-worth.
Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 3 of 5 residents (Residents #503, #161, and #60) reviewed for environment. 1. The facility failed to ensure Residents #503's bed curtain was free from a dried brown substance. 2. The facility failed to ensure the large hole in Resident #161's and #60's bedroom wall was repaired. These failures could affect any resident and place them at risk for not having a safe and sanitary homelike environment.
Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received proper treatment and assist the resident in making appointments for 1 of 1 resident (Resident #116) whose records were reviewed for vision services in that: Nursing staff failed to ensure that Resident #116 was scheduled for an ophthalmologist appointment since July 2023. This failure could affect residents and contribute to a decline in vision.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for 1 of 36 residents (Resident #146) reviewed for foot care. The facility did not ensure Resident #146 received toenail care. This failure could place residents at risk for not receiving foot care which is consistent with professional standards of practice.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 5 residents (Resident #113) reviewed with limited range of motion. The facility failed to ensure Resident #113 was receiving contracture management to treat their contracted hands. This failure could place residents at risk for decrease in mobility, range of motion, and contribute to worsening of contractures.
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 2 (Resident #153 and #250) of 11 residents reviewed for accidents. 1. The facility failed to ensure Resident #153, who resided in the secure unit, did not have access to a razor. 2. The facility failed to have a fall mat in place, while in bed, for Resident #250. These failures could place residents at risk for decline in health, and decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents to include providing pharmaceutical services including procedures that assure the accurate acquiring of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Resident #300) reviewed for medication administration. The facility failed to administer medication, Xtandi, to Resident #300 from 10/27/23- 11/08/23. This failure placed resident at risk of preventable pain and worsening of their medical conditions.
Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident #300) of 6 residents reviewed for medication errors was free of significant medication errors. The facility failed to obtain Xtandi (medication used in treatment of cancer) and administer medication per Physician Order. This failure placed the resident at risk of complications due to possible cancer spread.
Inspectors wroteBased on observation, 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 5 residents (Resident #113) reviewed for clinical records. The facility failed to ensure staff accurately documented on Resident #113's MAR on 11/07/23. This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records.
Inspectors wroteBased on observation, interview, 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, were reported immediately for 1 of 3 residents (Resident #1) reviewed for abuse reporting. The facility failed to ensure LVN A reported an allegation of sexual abuse involving Resident #1. This failure could place residents at risk for not having allegations of abuse reported.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one (Resident #1) of five residents reviewed for resident rights. The facility failed to ensure Dietary Aide B treated Resident #1 with respect and dignity in her interaction with him on 09/15/23 to which Resident #2 was a witness to. This failure led to the residents having feelings of being worried or scared.
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 the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of five residents (Resident #3) reviewed for ADL care. The facility failed to ensure Resident #3 received timely incontinent care. This failure could put residents at risk of impaired skin integrity and decreased feelings of self-worth and dignity.
9 fire safety citations on file: 4 on March 10, 2026, 3 on December 11, 2024, 2 on November 8, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| April 27, 2026 | Fine | $17,004 |
| April 27, 2026 | Fine | $17,004 |
| March 3, 2026 | Fine | $10,361 |
| March 3, 2026 | Fine | $23,371 |
| February 13, 2026 | Fine | $16,149 |
| June 19, 2025 | Fine | $17,345 |
| June 19, 2025 | Fine | $17,345 |
| February 26, 2025 | Fine | $16,149 |
| May 6, 2024 | Fine | $15,642 |
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) | 2.81 | 3.39 | 3.86 |
| Registered nurses | 0.17 | 0.43 | 0.69 |
| All nursing staff on weekends | 2.46 | 2.98 | 3.42 |
| Nurse aides | 1.70 | ||
| Licensed practical nurses | 0.94 | ||
| Nursing staff turnover (share who left in a year) | 41.5% | 55.3% | 45.8% |
| Registered nurse turnover | 66.7% | 54.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.74 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 2.96 on weekdays and 2.46 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.69 in April to June 2025 to 2.81 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 | 2.81 | 0.17 | 2.96 | 2.46 | 0.0% | 1 of 90 | 213 |
| Oct to Dec 2025 | 2.76 | 0.17 | 2.89 | 2.44 | 0.0% | 0 of 92 | 208 |
| Jul to Sep 2025 | 2.82 | 0.19 | 2.95 | 2.50 | 0.0% | 0 of 92 | 202 |
| Apr to Jun 2025 | 2.69 | 0.20 | 2.81 | 2.37 | 0.0% | 0 of 91 | 194 |
| 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 | 2.8 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.1 | 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 | 0.8 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.6 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 1.1 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 0.8 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 6.1 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 13.1 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 14.3 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Williamsburg Village Healthcare Campus's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (49.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
49.1% 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. 48 eligible stays.
10.9% 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. 48 eligible stays.
6.5% 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. 26 eligible stays.
64.0% 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. 25 residents counted.
2.1% 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. 47 residents counted.
3.2% 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. 47 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. 6 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: DALLAS COUNTY HOSPITAL DISTRICT. CMS links this home to Dallas County Hospital District, a group of 5 nursing homes averaging 3.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Dallas County Hospital District | 5% or greater direct ownership interest | Organization | 100% | 02/27/2015 |
| Umb Bank National Association | 5% or greater mortgage interest | Organization | 09/23/2021 | |
| Castaneda, Edmundo | Corporate officer | Individual | 01/10/2022 | |
| Cerise, Frederick | Corporate officer | Individual | 03/24/2014 | |
| Pf Williamsburg SNF Ops, LLC | Operational/managerial control | Organization | 09/23/2021 | |
| Stonegate Senior Living, LP | Operational/managerial control | Organization | 06/22/2022 | |
| Vernon, Gibson | Operational/managerial control | Individual | 01/08/2012 | |
| Campbell, Scott | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 12/04/2025 | |
| Chance, James | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 12/04/2025 | |
| Fisher, James | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 12/04/2025 | |
| Langdon, Thomas | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 12/04/2025 | |
| McGehee, William | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 12/04/2025 | |
| Taylor, John | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 12/04/2025 | |
| Lifetime Wellness, Ltd. | Adp of the SNF | Organization | 09/23/2021 | |
| Martus Financial Services, Inc. | Adp of the SNF | Organization | 12/31/2023 | |
| Pf Williamsburg SNF Ops, LLC | Adp of the SNF | Organization | 12/03/2025 | |
| Pharmerica Drug Systems LLC | Adp of the SNF | Organization | 08/27/2017 | |
| Preservation Freehold Company | Adp of the SNF | Organization | 09/23/2021 | |
| Rehab Pro LP | Adp of the SNF | Organization | 09/23/2021 | |
| Sanctuary LTC, LLC | Adp of the SNF | Organization | 09/23/2021 | |
| Stonegate Senior Living, LP | Adp of the SNF | Organization | 12/03/2025 | |
| Bailey, Cecil | Adp of the SNF | Individual | 03/15/2015 | |
| Boyd, Albert | Adp of the SNF | Individual | 07/01/2014 | |
| Hoffart, Tammie | Adp of the SNF | Individual | 07/06/2022 | |
| Vernon, Gibson | Adp of the SNF | Individual | 01/08/2012 |
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.