Afton Oaks Nursing and Rehabilitation Center
7514 Kingsley St, Houston, TX 77087 · Harris County · 169 certified beds · avg 77 residents/day · certified since Jan 21, 1987
Abuse citation flag (CMS)SFF Candidate
Part of chain: CREATIVE SOLUTIONS IN HEALTHCARE (149 facilities, chain avg rating 2.1★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Nov 21, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 22, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 27, 2025 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 28, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 27, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 28, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 27, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 28, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 27, 2025 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 28, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 27, 2025 · F-0698 · triggered by a complaint
The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Why it matters: Mistakes in dialysis care can quickly become life-threatening for residents with kidney failure.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 28, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 27, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 28, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jul 11, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
▲ Immediate jeopardy, one-off · Sep 13, 2023 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 5, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 13, 2023 · F-0609 · triggered by a complaint
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 5, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 14, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 21, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 27, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Oct 27, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 27, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Oct 27, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Oct 27, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Oct 27, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Oct 27, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 27, 2025 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Oct 27, 2025 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Oct 27, 2025 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. · from a complaint |
| Jul 11, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 9, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 9, 2025 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Apr 9, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Apr 1, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 1, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Apr 1, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Sep 13, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Sep 13, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 13, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 13, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 13, 2023 | ▲ J · Immediate jeopardy, one-off | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Sep 13, 2023 | ▲ G · Actual harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Nov 10, 2022 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Nov 10, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 2 | 0 | D |
| 2023 | 6 | 6 | J ▲ |
| 2024 | 3 | 0 | D |
| 2025 | 25 | 9 | K ▲ |
| 2026 | 1 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $90,872.
| Date | Type | Amount / length |
|---|---|---|
| Jan 14, 2026 | Fine | $14,722 |
| Oct 27, 2025 | Fine | $45,760 |
| Jul 11, 2025 | Fine | $10,529 |
| Sep 13, 2023 | Fine | $19,861 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.70 | 3.46 | 3.95 | top 25% in Texas; bottom 47% in the U.S. |
| Registered Nurse hours | 0.59 | 0.44 | 0.69 | top 16% in Texas; top 50% in the U.S. |
| Weekend total nurse staffing | 3.39 | 3.04 | 3.50 | top 20% in Texas; top 48% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.28 | 0.34 | 0.48 | bottom 47% in Texas; bottom 28% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 55.3 | 45.8 | — |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.59, RN 0.57, weekend 3.29. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bodie, Rebecca | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Diversicare Afton Oaks, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Garrett, Chandra | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Garrett, Chandra | Individual | ADP of the SNF | NOT APPLICABLE | 07/29/2025 |
| Jian, Peter | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/20/2025 |
| Jian, Peter | Individual | ADP of the SNF | NOT APPLICABLE | 07/29/2025 |
| Journey Medical PLLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/20/2025 |
| Murrell, Edward | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Nee, Stephen | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Rollo, Jeffery | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Stramecki, Anthony | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Vratis, Kacey | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Way, George | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Weishaar, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Winnie-Stowell Hospital District | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Courtyard | 0.7 mi | Houston, TX | ★★★★☆ | 5/5 | |
| Avir at Golfcrest | 1.1 mi | Houston, TX | ★★☆☆☆ | 2/5 | |
| Harmony Care at Golfcrest | 1.5 mi | Houston, TX | ★☆☆☆☆ | 1/5 | |
| Paradigm at Faith Memorial | 5.5 mi | Pasadena, TX | ★★★☆☆ | 3/5 | |
| St Dominic Village Rehabilitation and Nursing Cent | 5.5 mi | Houston, TX | ★☆☆☆☆ | 2/5 | abuse |
| Garden Terrace Healthcare Center of Houston | 6.0 mi | Houston, TX | ★★☆☆☆ | 1/5 | |
| Richard A. Anderson (state of Texas Veterans Land | 6.3 mi | Houston, TX | ★★★★★ | 4/5 | |
| Jacinto Nursing and Rehabilitation Center | 6.5 mi | Houston, TX | ★☆☆☆☆ | 2/5 | |
| Holly Hall | 6.5 mi | Houston, TX | ★★★☆☆ | 3/5 | |
| The Methodist Hospital SNF | 6.6 mi | Houston, TX | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 455682.