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 KHarm
Dignity & rights
Pattern; immediate jeopardy to resident health or safety.Corrected 2026-04-23Record 675254-20260422-F580
F692Provide enough food/fluids to maintain a resident's health.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2026-04-23Record 675254-20260422-F692
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-23Record 675254-20260422-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-23Record 675254-20260422-F656
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-13Record 675254-20260318-F656
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-13Record 675254-20260318-F726
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-13Record 675254-20260318-F755
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 2026-04-13Record 675254-20260318-F880
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-11-26Record 675254-20251125-F725
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-11-26Record 675254-20251125-F838
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 2025-12-09Record 675254-20251119-F761
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-12Record 675254-20250905-F656
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-12Record 675254-20250905-F925
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 675254-20250529-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 675254-20250529-F656
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-17Record 675254-20250516-F580
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 2025-05-17Record 675254-20250516-F657
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-24Record 675254-20240517-F760
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 2024-05-24Record 675254-20240517-F842
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 2024-05-01Record 675254-20240329-F580
F693Ensure 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.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-05-01Record 675254-20240329-F693
F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-01Record 675254-20240329-F636
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 2024-05-01Record 675254-20240329-F637
F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-01Record 675254-20240329-F640
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-01Record 675254-20240329-F641
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-01Record 675254-20240329-F759
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 2024-05-01Record 675254-20240329-F850
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity JHarm
Dignity & rights
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-11-27Record 675254-20231028-F580
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-11-27Record 675254-20231028-F695
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-10-30Record 675254-20230928-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-10-30Record 675254-20230928-F686
F567Honor the resident's right to manage his or her financial affairs.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-20Record 675254-20230127-F567
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-20Record 675254-20230127-F584
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-20Record 675254-20230127-F641
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-20Record 675254-20230127-F645
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-20Record 675254-20230127-F689
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 2023-02-20Record 675254-20230127-F758
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 2023-02-20Record 675254-20230127-F759
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-20Record 675254-20230127-F925