Fourth in the NursingHomesTexas.com data series. Texas's nursing-home industry is majority for-profit, unusually reliant on hospital-district ownership, and increasingly chain-operated. The inspection and penalty data shows a measurable quality gap by ownership - and a handful of operators carrying an outsized share of the worst findings.
The for-profit gap
Of Texas's 1,177 certified nursing homes, 825 (70%) are for-profit and 247 (21%) are government-owned - the latter overwhelmingly by hospital districts, a sector far larger than in most states. Only 105 (9%) are non-profit.
| Ownership class | Homes | Citations / home | Serious / home | Fines | Avg. star |
|---|---|---|---|---|---|
| For-profit | 825 | 29.1 | 2.43 | $39,749,412 | 2.51 |
| Government | 247 | 27.3 | 2.11 | $9,589,856 | 2.75 |
| Non-profit | 105 | 19.0 | 1.30 | $2,614,927 | 3.65 |
For-profit homes average 53% more citations and 87% more serious citations than non-profit homes, and account for 76% of all federal fines assessed in the state ($39.7M of $52.0M). Non-profit homes average more than a full star more in CMS's overall rating (3.65 vs 2.51).
The most common corporate form is the corporation: 414 of the for-profit homes are "For profit - Corporation," followed by 318 limited liability companies.
The chains with the worst per-home records
Grouping homes by CMS "Chain Name," among chains with four or more Texas homes, by serious (actual-harm or immediate-jeopardy) citations per facility:
| Chain | TX homes | Citations | Serious | IJ | Fines | Serious/home | Avg. star |
|---|---|---|---|---|---|---|---|
| Harmony Care Group | 6 | 261 | 33 | 26 | $769,193 | 5.50 | 1.60 |
| Chambers County Public Hospital District No. 1 | 7 | 180 | 33 | 24 | $384,728 | 4.71 | 3.00 |
| Paradigm Healthcare | 15 | 521 | 56 | 42 | $811,058 | 3.73 | 2.00 |
| Momentum Skilled Services | 9 | 197 | 33 | 32 | $492,120 | 3.67 | 2.11 |
| Ignite Medical Resorts | 7 | 211 | 25 | 15 | $438,228 | 3.57 | 2.71 |
| Focused Post Acute Care Partners | 25 | 847 | 87 | 75 | $1,747,338 | 3.48 | 1.96 |
| SLP Operations | 7 | 219 | 22 | 19 | $424,545 | 3.14 | 2.14 |
| Hamilton County Hospital District | 10 | 267 | 31 | 24 | $296,475 | 3.10 | 2.30 |
| Eduro Healthcare | 20 | 672 | 61 | 47 | $1,136,824 | 3.05 | 2.45 |
| Opco Skilled Management | 27 | 862 | 79 | 71 | $1,556,262 | 2.93 | 2.04 |
Harmony Care Group has the worst per-home severity rate of any sizeable chain - 5.50 serious citations per home, more than twice the statewide per-home average - on a 1.60-star average. Focused Post Acute Care Partners (25 homes) has accrued $1.75 million in fines with 75 immediate-jeopardy citations.
Look at the biggest operators
Texas's largest chains by footprint are Creative Solutions in Healthcare (149 homes) and Avir Health Group (118 homes) - together nearly 23% of all Texas facilities:
| Chain | TX homes | Citations/home | Serious/home | Fines | Avg. star |
|---|---|---|---|---|---|
| Creative Solutions in Healthcare | 149 | 30.8 | 2.58 | $8,213,875 | 2.09 |
| Avir Health Group | 118 | 33.1 | 2.67 | $6,763,032 | 2.27 |
| The Ensign Group | 85 | 27.6 | 2.24 | $2,584,838 | 2.67 |
| Wellsential Health | 67 | 27.4 | 1.79 | $2,338,036 | 2.73 |
| Cantex Continuing Care | 37 | 27.0 | 1.89 | $1,410,286 | 3.08 |
Creative Solutions in Healthcare alone accounts for $8.2 million in fines - 15.8% of every federal fine dollar assessed in Texas - while averaging 30.8 citations per home. Scale concentrates enforcement risk.
Repeat offenders: the facilities at the center of the data
Sorting facilities by serious citations reveals the homes where the system keeps finding harm:
| Facility | County | Cites | Serious | IJ | Fines | Star |
|---|---|---|---|---|---|---|
| Woodway Nursing & Rehab | Harris | 55 | 20 | 17 | $295,783 | - |
| Coral Rehabilitation and Nursing of Austin | Travis | 89 | 18 | 18 | $307,704 | - |
| Afton Oaks Nursing and Rehabilitation Center | Harris | 43 | 16 | 13 | $71,011 | 1 |
| Harmony Care at Beaumont | Jefferson | 77 | 15 | 12 | $373,869 | - |
| Willow Ridge Wellness & Rehabilitation | Tarrant | 38 | 14 | 11 | $321,244 | 1 |
| DFW Nursing & Rehab | Tarrant | 61 | 13 | 10 | $317,302 | 1 |
| Whispering Pines Lodge | Gregg | 59 | 12 | 12 | $494,425 | 1 |
| Terra Bella Health and Wellness Suites | Harris | 44 | 12 | 8 | $179,684 | 2 |
| Avir at Arden Wood | Harris | 32 | 12 | 9 | $130,388 | 2 |
| Viridian Wellness & Rehabilitation | Tarrant | 93 | 11 | 9 | $285,234 | - |
Nine of the ten most-cited facilities sit in the Houston, Dallas-Fort Worth and Austin metros. Woodway Nursing & Rehab recorded the most immediate-jeopardy citations of any facility (17) and also carries the most serious citations in the state. The worst homes are not spread evenly - they cluster in a handful of metro facilities, and 34.7% of all serious citations are concentrated in the worst-performing 10% of homes.
The fines
- $51,954,195 in federal civil money penalties, across 1,861 actions.
- Median fine: $14,838. 124 fines of $100,000+.
- Largest: $284,250 against Legacy at Town Creek, June 2024.
- Creative Solutions in Healthcare, Texas's largest operator (149 homes), accounts for $8.2M - 15.8% of all Texas fine dollars.
What this dataset is really showing
Three patterns run through all four studies:
- Ownership is a quality signal. The for-profit/non-profit gap is large, consistent, and visible in citations, serious citations, stars and fines.
- Problems cluster. A minority of homes and chains generate a majority of the worst findings - the worst 10% of homes produce 35% of all serious citations.
- Staffing is the mechanism. The worst chains are also among the most understaffed and highest-turnover (see Study 3). Profit extracted at the staff line reappears as citations.
Methodology
- Ownership class derived from CMS
Ownership Type: "For profit," "Non profit," "Government." Chain grouping uses CMSChain Name; only chains with >=4 TX homes shown. - Fines are federal civil money penalties (CMS Penalties file); fines by facility/chain are sums of all penalty events on record.
- "Serious" = severity G-L (actual harm or immediate jeopardy).
- Source: CMS Provider Data, processing date 2026-09-01. Derived from the public CMS datasets.
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