Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
7E
1F
Potential for minimal harm
0A
0B
0C
June 17, 2026Complaint inspection · 3 citations
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from any significant medication errors for two of 5 residents (Resident #1 and Resident #2) reviewed for medication errors. 1. The facility failed to hold Resident #1's midodrine (medication that raises blood pressure) when Resident #1's blood pressure was outside of physician's parameters on 06/01/26 and 06/11/26. 2. The facility failed to administer Resident #2's midodrine when Resident #2's blood pressure was inside of physician's parameters on 06/05/26. These failures could place residents at risk for complications such as increased blood pressure, decreased blood pressure, exacerbation of symptoms, and potential hospitalization.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #5) reviewed for documentation. The facility failed to ensure Resident # 5's medication orders were complete and accurate on 1 occasion for June 10, 2026. This failure could place residents at risk for errors in care and treatment and not receiving the services needed to attain or maintain their highest practicable physical well-being.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comprehensive prevention and control program that included employing proper signage on the doors of resident's room to prevent the transmission of communicable diseases and infections for 1 of 16 residents (Resident #4) reviewed for infection control. The facility failed to place a readily visible EBP sign outside the room of Resident's #4 who had an active order for EBP. This failure could place residents at risk of cross contamination, infection, and illness.
May 28, 2026Complaint inspection · 1 citation
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 residents (Resident #1 and Resident #5) of 5 residents whose care plans were reviewed. 1. The facility failed to ensure Resident #1's care plan addressed her sexual relationship with Resident #5. 2. The facility failed to ensure Resident #5's care plan addressed his sexual relationship with Resident #1. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs.
February 26, 2026Standard inspection · 8 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 5 of 8 (Resident #82, Resident #21 , Resident #53 , Resident #32, and Resident #1) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #82's oxygen was administered at the correct setting of 3 liters per minute on 2/24/2026 as ordered by the physician. 2. The facility failed to ensure Resident #21's oxygen was administered at the correct setting of 2 liters per minute on 2/24/2026 as ordered by the physician. 3. The facility failed to ensure Resident #53's oxygen was administered at the correct setting of 4 liters per minute on 2/24/2026 as ordered by the physician. 4. [...]
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #8) reviewed for pharmacy services. The facility failed to ensure Resident #8's blood pressures were assessed prior to administering Lisinopril (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in February of 2026. This failure could have placed residents at risk for complications and jeopardize their health and safety. The findings Included: Record review of Resident #8's face sheet, dated 02/26/2026, revealed an [AGE] year-old female with an admission date of 02/05/2026 and a discharge date of 02/25/2026. Pertinent diagnosis included Essential Primary Hypertension (high blood pressure). [...]
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 3 of 4 medication carts (100 Hall Nurse Med-Cart and 200/400 Hall and 300 Hall Medication Carts) reviewed for labeling and storage. 1. The facility failed to ensure the 100 Hall Nurse Med-Cart was locked and secured. 2. The OTC medications in the 200/400 Hall and 300 Hall Medication Carts did not have an open date written on the liquid and powder bottles. 3. The facility failed to ensure a (diabetic) lancet, sitting on top the unattended 200 hall medication cart, was used. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to properly label and date open, shelf stable food. The facility failed to dispose of expired shelf stable and refrigerated food. The facility failed to ensure boxes containing jugs of water were not on the floor. The facility failed to clean the filters on the ice machine. The facility failed to sweep, mop, and clean the floors and counters in the kitchen. The facility failed to ensure the refrigerators, as well as the trays inside the refrigerators, were clean. The facility failed to ensure the juice dispenser was clean. The facility failed to ensure the utensil drawer was clean. [...]
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure the resident had the right to personal privacy during medical treatment for 3 (Resident #15, Resident #82, and Resident #21) of 5 Residents reviewed for Privacy. The facility failed to ensure MA E closed the door or the curtain during medication administration for Resident #15 and Resident #82 on 02/25/2026. The facility failed to ensure LVN F closed the door, the curtain or the blinds during medication administration via gastrostomy tube for Resident #21 on 02/25/2026. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record reviews and interviews, the facility failed to send a copy of the residents ' discharge notice, including the reason for transfer or discharge, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 2 residents (Resident #3) reviewed for notifying the LTC Ombudsman of the residents ' discharge. Resident #3 was discharged home on [DATE] without a notice to the LTC state ombudsman. These failures could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #82) of 4 residents reviewed for medications. The facility failed to administer Carvedilol for Resident #82 per physician's order on 02/25/2026. This failure could place the residents at risk of not receiving therapeutic doses of their medication.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #21 and Resident #87) of 5 residents reviewed for infection control practices, in that: 1. The facility failed to ensure LVN F followed enhanced barrier precautions while administering medications via gastrostomy for Resident #21. 2. CNA I failed to remove contaminated gloves after catheter care prior placing clean brief on Resident #87 on 02/25/2026. This failure could place residents at risk for healthcare associated cross contamination and infections. 2. Record review of Resident #87's face sheet dated 2/26/26 revealed an [AGE] year-old female admitted originally on 2/17/26. [...]
December 18, 2025Complaint inspection · 1 citation
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 4 medication carts reviewed for labeling and storage. The facility failed to ensure the 100 Hall Nurse Medication Cart belonging to LVN-A and the 100 Hall Nurse Medication Cart belonging LVN-B were locked and secured. This failure could place the residents at risk of gaining access to unlocked medications which were not prescribed to them.
July 11, 2025Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review, the facility failed to report an alleged violation of abuse for (1 of 4 residents) in a timely manner. The facility failed to report to the state of Texas within 24 hours indicating Resident #1 hit her head, in a timely manner. R#1 hit her head during transport on March 7, 2005, the facility reported the incident 3 months later. This failure could place residents at risk for abuse and neglect.
November 14, 2024Standard inspection · 2 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on 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 and 1 of 1 nutrition room (ice room) reviewed for sanitation in that: 1. The facility failed to ensure the convection oven was opening properly and safely. 2. The facility failed to ensure [NAME] A did not place personal items on prep tables. 3. The facility failed to ensure [NAME] A were washing their hands. 4. The facility failed to ensure prep tables, the underside of the steam table shelf, and the underside of the stove shelf was clean and sanitized. 5. The facility failed to ensure a dented can of fruit was removed from the in-use shelf of cans. 6. The facility failed to ensure dry goods were sealed properly. 7. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for two residents (Resident #26 and Resident #118) of six residents observed for infection control practices in that: The facility failed to ensure the WCN performed adequate hand hygiene by scrubbing hands with soap for at least 20 seconds or greater before and after performing wound care on Resident # 26 and Resident #118. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections.
October 27, 2024Complaint inspection · 6 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 1 resident reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 15 minutes from 6:00 PM to 6:15 PM on 10/07/24 before a 3rd party called to notify the facility that Resident #1 was walking through a field adjacent to the facility. On 10/18/24 at 2:27 PM, an Immediate Jeopardy (IJ) was identified. [...]
- F
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 7 (Resident #2, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, and Resident #10) of 7 residents reviewed for clinical records. 1a. The facility failed to ensure that RN A documented Resident #2's blood pressure on the MAR (medication administration record) or in the vital signs when Resident #2 was given medication that would decrease her blood pressure in 5 of 16 opportunities reviewed for medication administration. 1b. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of three residents, one of one Central Supply Rooms, and one of twelve rooms on the 400 hall reviewed for infection control. 1.) The facility failed to ensure resident briefs were properly stored and out of reach from other residents, staff, and visitors to prevent possible cross-contamination. 2.) The facility failed to ensure Resident #2 was placed on transmission-based precautions when her urine culture result was positive for Klebsiella pneumoniae (a bacteria). [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life, for one (Resident #3) of five reviewed for dignity issues. Resident #3's foley catheter drainage bag did not have a privacy bag, leaving the urine in the bag visually exposed to visitors, staff, and other residents. This failure could place residents at risk of feeling uncomfortable and disrespected which could decrease residents' self-esteem and/or quality of life.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #12) of five residents reviewed for quality of care. The facility failed to present consistent accurate and detailed assessments of Resident #12's progressive injuries on 07/09/2024 after an unwitnessed fall, as an effort to ensure appropriate treatment was developed. There was no documented progress note, or skin assessments in Resident #12's electronic health record, detailing the injuries mentioned in Resident #12's 07/09/2024 emergency room transfer form, or incident report. [...]
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in one of one central supply rooms reviewed for environment in that: The central supply room door on the 200 hall was propped open with a large roll of plastic, allowing easy access to potentially harmful supplies such as razors and lancets. There were 9 full boxes of disposable razors on the shelves within reach and easily accessible. There was a full case of deodorant that expired on [DATE]. There were 33 cases of lancets (a sharp, spring-loaded pointed tool used to check blood sugars (finger sticks) accessible. These failures could place residents, staff, and visitors at risk of receiving incorrect care and cause health complications with subsequent illnesses, and injury.
March 30, 2024Complaint inspection · 2 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for NPO status. The facility failed to intervene timely and appropriately when Resident #2 obtainted food and began to choke. On 3/25/2024, during lunch service about 12:00 p.m., Resident #2 obtained access to Resident #1's food, staff did not provide timely interventions which led to Resident #2 choking and expiring. Resident #2 had a g-tube and was on NPO status. An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews and record review the facility failed to ensure residents receive adequate supervision to prevent accidents for 1 of 3 residents reviewed for NPO status. The facility failed to ensure Resident #1 was adequately supervised while eating lunch. On 3/25/2024, during lunch service about 12:00 p.m., CNA D did not ensure adequate supervision of Resident #1 while eating. Resident #2 obtained access to Resident #1's food, choked and died. Resident #2 had a g-tube and was on NPO status. An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. [...]
August 10, 2023Standard inspection · 7 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of five residents (Resident #1 and Resident #17) reviewed for infection control. 1. RN A did not perform hand hygiene nor glove change prior to administering medication via PEG-tube, as well as did not perform hand hygiene nor change of gloves prior to inserting tube feeding into peg tube for Resident #17. 2. CNA A did not perform hand hygiene nor glove changes during perineal care for Resident #1 These failures could place residents at risk for infection through cross contamination of pathogens.
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have physician orders for the resident's immediate care at the time the resident was admitted for 2 of 5 (Resident #41 and Resident #116) residents whose records were reviewed for physician orders in that: The facility failed to ensure there was an active order for PICC Line dressing changes for Resident #41. The facility failed to clarify physician orders for Heparin Flushes for Resident #41. The facility failed to clarify physician orders for Resident #116. These failures could place residents at risk of inadequate monitoring of medical conditions and not receiving the care and services to meet their needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided by the facility met professional standards of quality of care for 1 of 5 residents (Resident #54,) reviewed for quality of care. Wound Care Nurse did not follow the doctor's orders (pat dry wound) for treatment of wound care for Resident #54. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, 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 one of three residents (Resident #1) reviewed for pressure ulcer care and prevention. The facility failed follow physician orders and did not apply the hydrafera blue dressing to Resident #1's stage 4 right lateral ankle pressure ulcer. This failure could place residents at risk of improper wound management, the development of new pressure ulcers, deterioration in existing pressure ulcers, infection, sepsis, and pain.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on 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 one of two residents (Resident #17) reviewed for feeding tube care. The facility failed to follow Resident #17's physician's order of documenting Gastric Residual Volume. This deficient practice could place residents at risk of aspiration pneumonia or vomiting.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. The facility failed to ensure personal items were not stored in the refrigerator. 2. The facility failed to ensure spice containers were properly closed and sealed. 3. The facility failed to ensure utensils were in safe working order. 4. The facility failed to ensure the deep fryer was vented into the vent hood properly. 5. The facility failed to ensure the steam table wells was cleaned. 6. The facility failed to ensure the shelf above the steam table was cleaned. 7. The facility failed to ensure the thermometer was calibrated for food service. 8. The facility failed to ensure the cleaning schedule was being followed. [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on interviews and observation, the facility failed to dispose of garbage and refuse properly for 1 of 1 deep fryer reviewed for dispose of garbage and refuse properly. The facility failed to dispose of grease properly. This deficient practice could place residents at risk of the attraction of vermin and rodents and affect residents by exposing them to germs and diseases carried by vermin and rodents.
Fire safety inspections
3 fire safety citations on file: 1 on February 26, 2026, 1 on November 14, 2024, 1 on August 10, 2023.
Every fire safety citation3 citations
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 14, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 10, 2023 · Corrected (the home has a date of correction)