CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F580
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F609
F637Assess the resident when there is a significant change in conditionScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F637
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F657
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F677
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F759
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F761
F850Hire a qualified full-time social worker in a facility with more than 120 beds.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F850
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F880
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-06Record 675172-20260107-F944
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-09-23Record 675172-20250922-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity JHarm
Medication
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-02-10Record 675172-20250922-F755
F760Ensure that residents are free from significant medication errors.Scope/severity JHarm
Medication
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-02-10Record 675172-20250922-F760
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-09-23Record 675172-20250922-F761
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-09-23Record 675172-20250922-F880
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-05Record 675172-20241016-F695
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-05Record 675172-20241016-F727
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-05Record 675172-20241016-F758
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-05Record 675172-20241016-F842
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity KHarm
Medication
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-07-10Record 675172-20240617-F755
F760Ensure that residents are free from significant medication errors.Scope/severity KHarm
Medication
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-07-10Record 675172-20240617-F760
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity KHarm
Dignity & rights
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-10-06Record 675172-20231003-F580
F760Ensure that residents are free from significant medication errors.Scope/severity KHarm
Medication
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-10-06Record 675172-20231003-F760
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F558
F583Keep residents' personal and medical records private and confidential.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F583
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F644
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F655
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F677
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F695
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F727
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F757
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F758
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 675172-20230913-F761
F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Scope/severity CPaperwork
Dignity & rights
Widespread; potential for minimal harm.Corrected 2023-10-13Record 675172-20230913-F577
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2023-10-13Record 675172-20230913-F732
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity GHarm
Care planningRecords
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-09-01Record 675172-20230803-F656
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-09-01Record 675172-20230803-F689
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-01Record 675172-20230803-F686