There are approximately 1300 nursing homes in Texas. Nearly a quarter of those homes have serious deficiencies. There are so many that we can’t put them all on one blog post. What we can do is give you our bottom five list.
Most of the facilities on this list has been designated as a “special focus facility.” That means the list consists of nursing homes that have a history of serious quality issues or are included in a special program to stimulate improvements in their quality of care.
Before we begin, we remind readers that Medicare puts all this information online in their Nursing Home Compare website. It’s free and easy to use. Before a loved one moves into a skilled nursing facility, see how that facility measures up in terms of quality measures, staffing and safety.
Legend Oaks Healthcare and Rehabilitation North
Our worst? Legend Oaks Healthcare and Rehabilitation North, a for profit facility located at 12921 Misty Willow Drive in Houston. It is a for profit facility with 124 beds.
The company’s website says it is “North Houston’s premier location for short-term Rehabilitation and long-term care” That isn’t what Medicare found. In fact, according to a ProPublica study, Legend Oaks Healthcare of North Houston had the highest number of serious deficiencies of any skilled nursing facility in Texas. 18 serious deficiencies and 54 total.
From the most recent Medicare report we found this,
“Based on interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when a significant change in condition occurred for one of 45 residents reviewed for notification of change in condition, in that [resident’s] physician was not promptly consulted when the resident complained multiple times of chest pain, shortness of breath and experienced a nose bleed indicating a significant change in vital signs/condition. [Resident’s] representative was not notified of the resident's change in condition after the resident complained multiple times of chest pain, shortness of breath, experienced a nose bleed, and expired in the facility the same day.”
An extensive review of the chart notes show a nurse visited with the resident several times that day and noted his ongoing complaints including chest pains. According to the investigation, the nurse had not reviewed the physician’s orders for the patient and didn’t notify the doctor that the patient was complaining of chest pain and not being able to breathe.
An alert CNA told the nurse on four different occasions that the patient was having chest pains. Later that evening a different CAN found the patient dead. The investigation revealed that at least 4 different healthcare staff had visited with the resident and learned he was having chest pains or difficulty breathing. No one called the doctor or EMS to transfer the patient to the hospital.
If this was an isolated incident it would still be unacceptable. But it isn’t. Records show it is one of 18 serious incidents.
We don’t know if the resident’s death was preventable. But the nursing home had hours and hours to call the patient’s doctor or transport him to a hospital. They did neither. Instead everyone passed the buck and assumed someone else would take action. That is how people die.
The year before, another inspection reported the facility failed to properly take care of wounds on two patients and placed 69 patients at risk.
Benbrook Nursing and Rehabilitation Center
Next on our bottom ten list is Benbrook Nursing and Rehabilitation Center in Benbrook, Texas (a suburb of. Ft. Worth). The facility is operated by Senior Care Management, a Texas based operator of nursing homes in small communities across the state.
It’s Facebook page gives the facility five stars but inspection reports reveal 33 deficiencies, 12 of them serious. In fact, Medicare says there overall rating is much below average, health inspections were much below average, staffing was below average and quality measures below average. (Warning, their nearest competitor, Cityview Nursing and Rehabilitation Center in Ft. Worth has similarly bad ratings and was also cited for abuse.)
In 2017, inspectors made an immediate jeopardy finding against the facility after determining that residents were not always given their medications. As noted in the report, “These failures could affect all 74 residents by placing them at risk for death, exacerbation of medical conditions, and not receiving the therapeutic benefits of their medications.” Some residents had to be hospitalized.
The Westbury Place
Number three on our list takes us back to Houston. The Westbury Place is a for profit nursing home with 148 beds. It has 59 deficiencies, 8 of them serious.
Unlike the others on our list so far, the Westbury Place has the dubious distinction of being cited for abuse.
One of the violations that caught our eye was failing to properly care patients with pressure sores (bed sores). If not treated immediately, bedsores can worsen quickly and become septic. They are frequently fatal. With proper care, they are preventable. (See our post “Can I Sue a Nursing Home for Bedsores?”)
Pecan Valley Healthcare Residence
This 73 bed facility is a for profit nursing home located in San Saba , Texas, a small town located in central Texas between Austin and Dallas. The facility has 38 noted deficiencies, 5 of them labeled serious.
Sadly, for residents in the San Saba area, 8 of the 10 nearby nursing facilities had at least one “much below average” rating on Medicare compare.
Trisun Care Center - Westwood
Number five on our list is a 94 bed for-profit facility in Corpus Christi. It has a shocking 61 deficiencies, 3 of them serious.
In its most recent 2019 inspection report, Trisun Care Center – Westwood (also known as Trisun Care Center – River Ridge) had 13 deficiencies, down from 24 in 2018.
If there is any good news, its that Trisun has managed to achive an overall rating of average and a quality measures rating of much above average. We hope the facility continues to improve.
The down side is 61 deficiencies and a staffing rating of much below average. In our opinion, inadequate staffing is a leading cause of falls, choking incidents, bedsores and medication errors. If you don’t have enough people on the floor, accidents and mistakes are bound to happen.
Retama Manor Nursing Center – Dishonorable Mention
Another for profit nursing home in Corpus Christi, Retama Manor Nursing Center is a large, 176 bed for profit facility. It had 73deficiencies in recent years, 10 of the serious and was also flagged by Medicare for nursing home abuse. It also has a “much below average” overall rating as well as much below average for health inspections. In fact, it didn’t achieve average or higher in any category.
The most recent inspection report is from 2018. It found the nursing home failed to notify a patient’s doctor when there was a need to alter treatment and a significant change in the patient’s status. As a result, the patient had to be hospitalized because of a flesh eating bacteria.
Nursing homes function as the eyes and ears of physicians. That is why they are designated as “skilled nursing facilities.” Many residents of nursing homes have diminished immune systems and difficulty communicating. When coupled with infrequent family visits, residents become especially at risk for serious health problems. The standard of care in every state dictates that staff alert the resident’s treating physician when there is a significant change of patient’s status.
The records show that the resident had a fall on November 10th, 2018. (We believe most falls are preventable. Falls often occur when a facility has inadequate staff. When call buttons don’t get answered or single staff members attempt to move a patient because a 2nd staff member isn’t available accidents happen.)
By the 12th, the resident had a significant bruise. By the 14th, the bruise was now a stage 2 bedsore. At that point, there is a high risk of infection. At that point the resident was transferred to the hospital. By nightfall he was semi-comatose. The resident at this point was suffering from a flesh eating bacteria.
From what we can tell, no one from the nursing home notified the resident’s doctor of the fall. It also appears they waited too long before seeking hospital treatment.
That same inspection also determined from a review of 10 patient records, that for 7 of those residents, Retama Manor “failed to keep residents free from abuse, neglect, misappropriation of resident property, and exploitation.”
Texas Worst Nursing Homes
Admittedly our ratings are a bit arbitrary. We used the data from ProPublica and Medicare. We did not use Facebook or other ratings which we feel are even more arbitrary.
Often when we write one of these posts we receive a cease and desist letter. We don’t take down posts simply because a nursing home doesn’t like their dirty laundry aired.
What we will do, however, is remove information about a specific nursing home if that facility can prove it has cleaned up its act and is not on a special focus list, has not been cited in the last three years for abuse AND has achieved an overall rating of ‘Much Above Average” by Medicare.
We want people to find quality care. Our seniors, disabled and loved ones deserve the best care possible. If you are delivering that care and meet the above criteria, we will happily remove you from our list.
If you or a loved one died or suffered a serious injury because of serious neglect or nursing home abuse, contact us. We investigate cases everywhere in the United States. In states where we are not licensed we co-counsel with one of our local partners.
Our goal is simple, make sure nursing home residents are treated with dignity and respect, are free from abuse and receive the best care possible.
To learn more, visit our nursing home neglect information page. Ready to see if you have a case? Contact us by email [hidden email], by phone 833.201.1555 or contact us online.