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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D12 | E8 | F9 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Dec 11, 2025 | Fire safety | Fire Safety Standard | 0 | No citations | — | Open → |
| Dec 11, 2025 | Health | Health Standard | 5 | Potential harm | — | Open → |
| Aug 30, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 16, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Sep 19, 2024 | Fire safety | Fire Safety Standard | 5 | Potential harm | — | Open → |
| Sep 19, 2024 | Health | Health Complaint, Health Standard | 4 | Potential harm | — | Open → |
| Jan 31, 2024 | Health | Infection Control | 0 | No citations | — | Open → |
| Jul 27, 2023 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Jul 27, 2023 | Health | Health Standard | 8 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D12 | E8 | F9 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Dec 11, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 31, 2025 | |
| Dec 11, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 31, 2025 | |
| Dec 11, 2025 | F-0656 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates 37 facilities.
5 facilities in 1 states. CMS chain ID 844.
Chain average overall rating (CMS): 3.4
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Dallas County Hospital District | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Mar 31, 2017 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Dallas County Hospital District | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Mar 31, 2017 |
| Douglas Boulware | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Jun 25, 2026 |
| Pmg Opco - Cleburne, LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 1, 2026 |
| William Bauder | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Windsor Gardens 2535 W Pleasant Run, Lancaster, TX 75146 CCN 455832 | 150 | Jul 20, 2026 | 342 IJ | $14k | |
| Avir at River Valley 1907 Refinery Rd, Gainesville, TX 76240 CCN 455970 | 116 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Denton Rehabilitation and Nursing Center 3345 Medpark Dr., Denton, TX 76210 CCN 675136 | 94 | Jul 16, 2026 | 32 | — | |
| Williamsburg Village Healthcare Campus 940 York Drive, Desoto, TX 75115 CCN 675756SFF Candidate | 242 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr, Cleburne, TX 76033 CCN 675748 | 3.1 km | 122 | Aug 6, 2026 | 272 IJ1 harm | $67k | |
| Colonial Manor Nursing Center 2035 N Granbury St, Cleburne, TX 76031 CCN 455631Abuse icon | 4.9 km | 137 | Apr 9, 2026 | 142 IJ1 harm | $52k | |
| Town Hall Estates Keene Inc 207 S Old Betsy Rd, Keene, TX 76059 CCN 676047 | 12.3 km | 126 | Aug 4, 2026 | 252 harm | $16k | |
| Alvarado Meadows Nursing & Rehabilitation 101 N Parkway, Alvarado, TX 76009 CCN 455601 | 22.4 km | 115 | Jul 2, 2026 | 252 IJ | $67k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 676197 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 676197 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care |
| D · Potential harm Isolated |
| Corrected Dec 31, 2025 |
| Dec 11, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 31, 2025 |
| Dec 11, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Dec 31, 2025 |
| Aug 30, 2025 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 31, 2025 | Complaint |
| May 16, 2025 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 17, 2025 | Complaint |
| May 16, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 17, 2025 | Complaint |
| Sep 19, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 31, 2024 |
| Sep 19, 2024 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 31, 2024 |
| Sep 19, 2024 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 31, 2024 |
| Sep 19, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 31, 2024 |
| Sep 19, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 31, 2024 |
| Sep 19, 2024 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 31, 2024 | Complaint |
| Sep 19, 2024 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 31, 2024 | Complaint |
| Sep 19, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 31, 2024 | Complaint |
| Sep 19, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Oct 31, 2024 | Complaint |
| Jul 27, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 1, 2023 |
| Jul 27, 2023 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 27, 2023 |
| Jul 27, 2023 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 30, 2023 |
| Jul 27, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 13, 2023 |
| Jul 27, 2023 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 24, 2023 |
| Jul 27, 2023 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 17, 2023 |
| Jul 27, 2023 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 18, 2023 |
| Jul 27, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 18, 2023 |
| Jul 27, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 18, 2023 |
| Jul 27, 2023 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Aug 25, 2023 |
| Jul 27, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Sep 1, 2023 |
| Jul 27, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Sep 1, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.37 (case-mix index 1.34).
| May 1, 2026 |
| Eyad Kakish | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 1, 2026 |
| Daniel Whitehead | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 1, 2026 |
| Edmundo Castaneda | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 10, 2022 |
| Bauder Family Investments, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Boulware St James LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Pmg Realco - Cleburne LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Steven Boulware Family Investments LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Kelly Bauder | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Madison Bauder | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Parker Bauder | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| William Bauder | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Steven Boulware | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Thomas Boulware | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Eyad Kakish | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Katie Walker | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Daniel Whitehead | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 1, 2026 |
| Jul 27, 2026 |
41 |
| — |
| Denton Rehabilitation and Nursing Center 3345 Medpark Dr., Denton, TX 76210 CCN 675136 | 94 | Jul 16, 2026 | 32 | — |
| Meadowbrook Care Center 632 Windsor Way, Van Alstyne, TX 75495 CCN 675151 | 60 | May 5, 2026 | 251 IJ | $14k |
| The Manor at Seagoville 2416 Elizabeth Ln, Seagoville, TX 75159 CCN 675418 | 90 | Apr 1, 2026 | 382 IJ | $98k |
| Renaissance Care Center 1400 Blackshill Dr, Gainesville, TX 76240 CCN 675441 | 91 | Jun 4, 2026 | 42 | — |
| Beacon Hill 3515 S Park Ave, Denison, TX 75020 CCN 675503 | 150 | May 26, 2026 | 28 | — |
| Williamsburg Village Healthcare Campus 940 York Drive, Desoto, TX 75115 CCN 675756SFF Candidate | 242 | Jul 30, 2026 | 939 IJ | $150k |
| Jul 30, 2026 |
939 IJ |
| $150k |
| Town East Rehabilitation and Healthcare Center 3617 O'hare Dr, Mesquite, TX 75150 CCN 676146Abuse icon | 130 | Jul 9, 2026 | 432 IJ1 harm2 open | $26k |
| Prestonwood Rehabilitation & Nursing Center 2460 Marsh Ln, Plano, TX 75093 CCN 676156 | 132 | Aug 13, 2026 | 273 IJ1 harm | $29k |