Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Phoenix Post-acute during CMS and state inspections, most recent first.
Duplicate Baclofen Orders Led to Unnecessary Medication Therapy. A resident with Tourette's Disorder, cognitive communication deficit, and ataxic gait had two active Baclofen orders with different doses in the chart, and the MAR showed both doses were administered on the same day. During observation, a CMA prepared to give Baclofen 15 mg and then identified the duplicate orders after reviewing the MAR. Interviews with the CMA, LVN, DON, and PA confirmed the lower-dose Baclofen order had not been discontinued when the new order was entered.
A facility failed to provide residents with reasonable access to private phone use, as reported by a resident with depression who could only make calls at the nurse's station, where conversations were overheard. The DON and Administrator confirmed the lack of a designated private area for phone use, and the facility was working on creating a private phone area but had no current policy on phone use and privacy.
An expired Levothyroxine 88 mcg blister pack was found on a medication cart, despite being discontinued months earlier for a resident with Alzheimer's and hypothyroidism. Staff interviews revealed inconsistent medication cart checks, leading to the oversight. The facility's policy required the removal of expired drugs, but this was not followed.
A resident with a full code status was found unresponsive outside the facility, but CNAs failed to initiate CPR before EMS arrived. The CNAs were not CPR certified, and the facility had not provided recent CPR training. The DON confirmed that CPR certification was not required for staff, and a Code Blue was not called. The facility's policy required CPR-certified staff to be available 24/7, but this was not followed.
A resident with severely impaired cognition eloped from an LTC facility and was found unresponsive, leading to their death. The facility lacked an effective system to track residents entering and exiting, and staff were unaware of the resident's absence. There was no receptionist after 10:00 p.m., and staff were not familiar with procedures for monitoring residents at risk of elopement.
Duplicate Baclofen Orders Led to Unnecessary Medication Therapy
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not maintained for Resident #79 when the facility failed to prevent duplicate medication therapy. Resident #79 was a male resident with diagnoses including Tourette's Disorder, Cognitive Communication Deficit, and Ataxic Gait, and his most recent MDS showed a BIMS score of 15 indicating intact cognition. Record review showed two active Baclofen orders in the resident's chart: Baclofen 10 mg by mouth three times daily for pain and Baclofen 15 mg by mouth three times daily for muscle relaxation, both with no end date. The MAR showed the resident received both Baclofen doses on multiple occasions, including Baclofen 10 mg and Baclofen 15 mg on the same day at different times. During observation, a CMA prepared to administer Baclofen 15 mg to the resident and then reviewed the orders after being stopped by the surveyor, noting the duplicate Baclofen orders. Interviews with the CMA, LVN, DON, and PA confirmed the Baclofen 10 mg order had not been discontinued when the Baclofen 15 mg order was entered. The facility policy stated staff and practitioners should minimize adverse consequences by following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication.
Lack of Privacy for Resident Phone Use
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically telephones. Resident #12, a cognitively intact individual with a diagnosis of depression, reported that the only available phone for resident use was located at the nurse's station, where conversations could be overheard by staff and passersby. The resident expressed discomfort and a lack of privacy during phone calls, as the facility did not provide cordless phones or a private area for phone use. The resident was limited to 15 minutes of phone use due to the nursing staff's need for the phone, and no alternative private phone options were offered. Interviews with the Director of Nursing (DON) and the facility Administrator confirmed the lack of a designated private area for residents to make phone calls. The DON acknowledged that the nurse's station was the only area for phone use, and many alert residents had their own cell phones. The Administrator mentioned that residents could use the phone at the nurse's station, receptionist desk, or in the Administrator's office if needed, but there was no designated area for private phone use. The facility was in the process of designating the physician's office as a resident phone area, but currently, there was no policy on resident phone use and privacy.
Expired Medication Found on Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles, as evidenced by the presence of an expired Levothyroxine 88 mcg blister pack on a medication cart. This medication was intended for a resident with a history of Alzheimer's disease, dementia, schizoaffective disorder, and hypothyroidism. The Levothyroxine 88 mcg was discontinued in October 2024, and a new prescription for Synthroid 100 mcg was initiated. Despite this change, the expired medication remained on the cart, indicating a lapse in the facility's medication management practices. Interviews with various staff members, including LVNs, medication aides, and the acting DON, revealed inconsistencies in the frequency and thoroughness of medication cart checks. While some staff reported checking for expired medications weekly, others mentioned biweekly or monthly checks. The pharmacist also conducted biweekly checks, but the expired medication was still overlooked. The facility's policy required discontinued or outdated drugs to be returned to the pharmacy or destroyed, but this procedure was not followed in this instance. The oversight was attributed to the medication being missed during routine checks, as stated by LVN A. The ADONs and other staff acknowledged that the responsibility for removing expired medications lay with the nurses and CMAs. Despite these checks, the expired Levothyroxine remained on the cart, posing a risk of administration errors. The resident involved did not report any issues with their medication, although they mentioned refusing multiple pills offered by the facility.
Failure to Provide CPR to Unresponsive Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who was found unresponsive, despite having a full code status. The incident involved two CNAs, CNA A and CNA M, who did not initiate CPR when the resident was discovered unresponsive outside the facility. The resident, who had a primary diagnosis of encephalopathy, was found on the ground with blood coming from his mouth. EMS was called approximately 10 minutes after the resident was found, and CPR was only initiated upon their arrival. Interviews with the CNAs revealed that neither was CPR certified, nor had they received CPR training while employed at the facility. The Director of Nursing (DON) confirmed that the facility did not require CNAs and nurses to be CPR certified and that no recent CPR training had been provided. The DON also stated that a Code Blue was not called, and there was no clear explanation of the facility's expectations for staff in such emergencies. The Operations Manager was unable to provide a timeline of the incident or identify the system failure. The report highlights that the facility's policy required staff certified in CPR to be available 24 hours a day, yet this was not adhered to. Additionally, interviews with other CNAs indicated a lack of familiarity with CPR response times and the use of an AED machine. The facility's failure to ensure staff were trained and certified in CPR, as well as the lack of immediate action when the resident was found unresponsive, contributed to the deficiency.
Resident Elopement and Lack of Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who was found unresponsive behind the facility. The resident, who had a primary diagnosis of encephalopathy and severely impaired cognition, was not accounted for during the night shift. Multiple staff members, including CNAs and a nurse, were unaware of the resident's absence, and an elopement code was not initiated. The resident was later found unresponsive with blood coming from his mouth and was pronounced deceased at the hospital. The facility lacked an effective system to track residents entering and exiting the building. Observations revealed that there was no receptionist or staff member present at the desk to monitor exit-seeking residents at the front door. Interviews with staff indicated that they were not familiar with the resident roster list, which identified residents needing assistance when exiting, and could not explain who was responsible for escorting these residents. Additionally, there was no clear policy on how frequently staff should round on residents, and the facility had not addressed the resident's history of leaving without signing out. The Director of Nursing (DON) and the Operations Leader were aware of the lack of a receptionist at the front desk after 10:00 p.m. and the absence of staff training to address this issue. The DON admitted that there was no policy specifying how frequently staff should round on residents and that previous elopements had not been adequately addressed. The facility's failure to provide sufficient supervision and implement effective tracking and monitoring systems contributed to the resident's elopement and subsequent death.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Texas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Point Skilled Nursing | 1.9 mi | ★★★★★ | 9 | 0 |
| Seabreeze Nursing And Rehabilitation | 5.1 mi | ★★★★★ | 8 | 0 |
| The Shoal | 5.2 mi | ★★★★★ | 5 | 0 |
| The Lakes At Texas City | 6.3 mi | ★★★★★ | 15 | 1 |
| Bayou Pines Care Center | 6.8 mi | ★★★★★ | 4 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.