 The federal government is pulling back from nursing home oversight. The minimum staffing rule is gone. Ownership transparency requirements are suspended. CMS has signaled that more rollbacks are coming. A June 5, 2026, opinion piece in McKnight's Long-Term Care News by Vivian Zayas, co-founder of Voices for Seniors and a congressional witness on nursing home accountability, made an argument worth taking seriously: deregulation does not protect nursing home residents. It does not protect their families. And, she argues, it does not protect operators either.
Ms. Zayas lost her mother in a nursing home. She has spent years in legislative hearings, watching what happens when a crisis lands on an industry that cannot point to clear standards it met. Her column in McKnight's was addressed to owners, operators, administrators, and directors of nursing, not to families and not to lawyers. That framing matters. She is not making a plaintiff's argument. She is making a governance argument. The two are not the same, but from where families in Texas sit, they arrive at the same place. When oversight recedes, residents bear the consequences first. Texas families need to understand what is being removed, why it matters, and what legal protections still exist when a nursing home fails. What Federal Nursing Home Protections Have Already Been Rolled Back? The most consequential recent rollback is the federal minimum staffing rule. CMS finalized a rule in 2024 requiring nursing homes to provide a minimum of 3.48 total nursing hours per resident per day, including at least 0.55 hours from a registered nurse and 2.45 hours from a nurse aide. The rule also required a registered nurse to be on-site 24 hours a day, seven days a week. That rule has since been rescinded. Ownership transparency requirements have also been suspended. Those requirements would have forced nursing homes to disclose the full web of entities involved in their ownership and management, including the related-party real estate companies and management companies that a September 2025 National Bureau of Economic Research working paper found were used to hide 68 percent of the industry's profits from regulators. Without transparency requirements, families and regulators cannot readily identify who is actually responsible when something goes wrong at a facility. Ms. Zayas described the current regulatory direction as CMS telling the industry that more is coming, more flexibility, more relief, more rollback of what the agency calls burden. The trade associations are being listened to. For families placing a loved one in a Texas nursing home today, the practical consequence is a federal floor that is lower than it was two years ago and getting lower. What Does Deregulation Actually Mean When Something Goes Wrong? Ms. Zayas makes a specific argument in her McKnight's column that deserves direct attention from Texas families: when there is no federal floor for staffing, every bad outcome becomes a question of what an owner or operator chose to provide, not what they were required to provide. That is a legal observation as much as a policy one. In a Texas nursing home neglect case, the standard of care is the central question. It defines what the facility was obligated to do and whether it fell short. Federal regulations are one source of that standard. State regulations are another. When federal minimums are eliminated, the regulatory floor shrinks. The facility's obligation does not disappear, but the clearest external benchmark for what adequate staffing looks like becomes harder to point to. Ms. Zayas writes that when oversight is weak and something goes wrong at scale, the response is not targeted. It is sweeping. That observation reflects what happens in crisis: the industry as a whole gets scrutinized, good operators and bad ones alike. For individual families, though, the crisis is not abstract. It is the fall that broke a hip. It is the pressure wound that went unnoticed for days. It is the infection that spread because no one caught it in time. Those injuries happen at specific facilities, and they happen to specific people. The legal question after a preventable injury is always whether the facility met its duty of care. Deregulation makes that question harder to answer with a clear standard, but it does not make it disappear. Texas law imposes its own requirements on nursing facilities independently of federal minimums. What Legal Obligations Do Texas Nursing Homes Still Have? Federal deregulation does not eliminate Texas law. The obligations Texas nursing homes carry are grounded in state statute and state administrative code, and they remain enforceable regardless of what CMS does with federal minimums. Under Texas Administrative Code Chapter 554, Texas imposes specific staffing sufficiency requirements. The standard is functional: staffing must be sufficient to meet residents' needs. There is no fixed numerical floor identical to the rescinded federal rule, but the sufficiency obligation is independently enforceable under state law. Under 26 Tex. Admin. Code §554.701(a), every licensed nursing facility in Texas must provide care that meets the needs of its residents and maintains their highest practicable physical, mental, and psychosocial well-being. In fact, under 26 Tex. Admin. Code §554.1921(a), Texas nursing homes are not even allowed to have a resident in their facility whose needs they cannot meet. That is not a suggestion. It is a statutory obligation, and it applies to every facility in the state whether or not a federal staffing minimum is in force. Under 26 Tex. Admin. Code §554.1001, Texas requires facilities to provide adequate nursing staff to meet each resident's assessed needs around the clock. A facility that runs short on nursing staff and a resident is harmed as a result is not protected from liability simply because a federal rule no longer specifies the minimum number of hours required. The Texas Health and Human Services Commission enforces these standards through surveys and inspections. When a facility falls below them, CMS can still issue deficiency citations under 42 CFR Part 483 for Medicare and Medicaid-certified facilities. The rollback of the staffing minimum rule does not eliminate the broader federal conditions of participation that all certified facilities must meet. For purposes of a civil negligence claim, the standard of care is not defined by federal regulation alone. Courts look to accepted professional standards in the nursing home industry, expert testimony, and the specific circumstances of the resident's care. A facility that provided staffing levels its own clinical assessments showed were insufficient to meet a resident's needs is not shielded by the absence of a federal floor. Why Does Ownership Transparency Matter to a Texas Family? The suspension of ownership transparency requirements has a direct practical effect on families pursuing legal claims. It makes it harder to identify the full set of entities responsible for a resident's care. Modern nursing home ownership is frequently structured across multiple entities. The licensed facility is one entity. The real estate may be owned by a separate company. Management may be contracted to another. Staffing may run through a separate employer of record. These structures are documented in the NBER working paper by Gandhi and Olenski, which found that 77 percent of U.S. nursing homes transact with related parties and that those transactions are a primary mechanism for moving profits and assets off the facility's books. When a resident is harmed, a lawyer needs to know which entities were involved in operational decisions, which entities hold assets that can satisfy a judgment, and how those entities relate to each other. Transparency requirements that forced disclosure of ownership structures made that analysis faster and less expensive. Their suspension means the information still exists but requires more work to uncover, through discovery, corporate filings, and regulatory records requests. Ms. Zayas puts it directly in her McKnight's column: when ownership structures are opaque, every tragedy invites scrutiny of everyone because no one can quickly identify who is actually responsible. That is as accurate a description of the litigation discovery process as it is of the regulatory one. What Is the Argument That Deregulation Actually Hurts Operators? Ms. Zayas directs her column at owners, operators, administrators, and directors of nursing, not at families or advocates. Her argument to them deserves a fair summary because it reinforces the case for standards from an unexpected direction. Her core claim is that the absence of enforceable standards does not protect an operator when something goes catastrophically wrong. It exposes them. Without a federal floor to point to, a bad outcome becomes a question of what the operator chose, not what was required. Without transparency requirements, a crisis sweeps across the industry without distinguishing good actors from bad ones. Without clear standards, the operators who are doing things right have no way to demonstrate that publicly. She writes that she has been in congressional hearings and has seen what happens when an industry cannot point to standards it met and say, here is the proof. The absence of standards does not protect operators. It leaves them exposed to the same scrutiny as the worst facilities in the country. From a litigation standpoint, that analysis is correct. A facility that can demonstrate it met or exceeded every applicable standard is in a fundamentally stronger position than a facility operating in a deregulated environment where what it provided is the only reference point. Standards create a floor. They also create a ceiling that good operators can point to and say they cleared. What Should a Texas Family Do If a Loved One Was Harmed in a Nursing Home? The rollback of federal nursing home oversight makes it more important, not less, to act quickly and document carefully if something goes wrong. Texas law still provides a legal remedy. Take these steps immediately.
We Can Help At The Borah Law Firm, PLLC, we represent patients and families across Texas in medical malpractice cases. We only handle these cases — nothing else. If you believe a loved one received substandard nursing home care, we can help you understand whether a case exists and what your options are. Contact us today for a confidential case review. Frequently Asked Questions Did the federal government eliminate nursing home staffing requirements entirely? The specific federal minimum staffing rule finalized in 2024, which required 3.48 total nursing hours per resident per day and a 24-hour registered nurse presence, has been rescinded. That does not mean nursing homes face no staffing obligations. CMS conditions of participation under 42 CFR Part 483 still require facilities to maintain sufficient nursing staff to meet residents' needs. Texas imposes its own staffing sufficiency requirements under Texas Administrative Code Chapter 554. Both remain enforceable. Can I still sue a Texas nursing home for understaffing if federal minimums have been removed? Yes. A medical malpractice claim under Texas Civil Practice and Remedies Code Chapter 74 does not depend on the existence of a federal staffing minimum. The standard of care is established through state law, accepted professional standards, and expert testimony. A facility that provided staffing levels its own clinical assessments showed were insufficient to meet a resident's needs can be held liable for resulting harm regardless of whether a federal rule specified a numerical floor. What is Voices for Seniors? Voices for Seniors is a Long Island, New York-based grassroots organization co-founded by Vivian Zayas and other families who lost loved ones in nursing homes. Ms. Zayas testified before the Select Subcommittee on the Coronavirus Pandemic in May 2023 and has advocated for nursing home residents and their families at the state and federal level. Her June 5, 2026, opinion piece in McKnight's Long-Term Care News addressed nursing home owners, operators, and administrators directly, arguing that deregulation exposes the industry to greater liability and reputational harm when crises occur. What is the ownership transparency requirement that was suspended? CMS had proposed requiring nursing homes to disclose the full network of entities involved in their ownership, management, and operations, including related-party real estate companies and management companies that share ownership with the facility. That requirement has been suspended. The practical effect is that families and regulators cannot as readily identify all entities involved in a facility's operations from public disclosures alone. A September 2025 NBER working paper by Gandhi and Olenski documented that these ownership structures are used by 77 percent of U.S. nursing homes to move profits into related entities. Does deregulation affect my ability to collect a judgment against a nursing home in Texas? Potentially yes, in two ways. First, the suspension of ownership transparency requirements makes it harder to quickly identify all entities that hold assets traceable to the facility's operations. Second, the rollback of the minimum staffing rule removes one clear external benchmark that plaintiffs have used to establish what constitutes adequate care. Neither change eliminates a legal claim, but both affect the investigative and evidentiary work required to pursue one effectively. An attorney experienced in Texas nursing home cases can advise on discovery strategies for tracing ownership structures and establishing the applicable standard of care. About the Author: J.T. Borah is a Texas medical malpractice attorney and founding attorney of The Borah Law Firm, PLLC, in Austin, Texas. His practice is limited exclusively to medical malpractice cases involving hospitals, nursing homes, and other medical institutions. He has been recognized as a Texas Super Lawyer. He is often asked to lecture at legal seminars on medical malpractice issues and has lectured to attorneys from 18 states. AI writing tools assisted Mr. Borah in preparing this article. All legal standards, citations, and factual claims were reviewed by Mr. Borah as a licensed Texas attorney. This article is for general informational purposes only and does not constitute legal advice. Reading this article does not create an attorney-client relationship.  The nursing home industry has spent decades telling regulators, legislators, and courts the same thing: we cannot afford to do better. Profit margins are thin. Medicaid rates do not cover costs. New staffing requirements will bankrupt facilities and force closures. A peer-reviewed study published by the National Bureau of Economic Research dismantles that argument with data.
Economists Ashvin Gandhi of UCLA Anderson and Andrew Olenski of Lehigh University published a working paper titled Tunneling and Hidden Profits in Health Care through the NBER in March 2024, revised September 2025. Their conclusion: 68 percent of nursing home profits are systematically hidden from regulators, legislators, and malpractice claimants through a practice called tunneling. The facilities are not poverty-stricken. They are making money and they are making lots of it. Then they move it. This finding has direct consequences for Texas families involved in nursing home neglect cases, for policymakers setting Medicaid reimbursement rates, and for courts evaluating whether understaffing reflects a genuine resource constraint or a deliberate financial choice. What Is Tunneling, and How Does It Work in Nursing Homes? Tunneling is the transfer of profits and assets out of a closely monitored entity into related companies owned by the same person or group. The term describes the process of removing assets through an underground tunnel, moving value off the books of the entity that regulators watch and onto the books of entities they do not. In nursing homes, tunneling works through two primary mechanisms: related-party real estate transactions and related-party management fees. Both are documented in the Gandhi and Olenski study using more than two decades of Illinois nursing home financial data, a dataset that is uniquely detailed because Illinois has required nursing homes to report related-party transactions for longer than most states. The real estate mechanism works through a sale-leaseback transaction. The nursing home sells its building to a company owned by the same operator, then pays that company rent to stay in the same building it just sold. The nursing home's direct ownership costs, depreciation, interest, and taxes, go down. But the rent paid to the related party more than replaces those savings. The study found that transitioning to a related-party real estate arrangement increases a facility's yearly real estate costs by an average of $1,744 per bed, a 42.4 percent increase over the mean. The property sale itself is a second tunneling opportunity. The study found that related parties typically buy nursing home real estate at a significant discount to its actual value. The researchers estimated that an average of $54,396 per bed in asset value is transferred off the nursing home's balance sheet in a typical related-party property sale. By 2019, they calculated that approximately 19.6 percent of the entire industry's real estate value had been moved off nursing home balance sheets through these transactions. The management fee mechanism is structurally identical. The nursing home stops paying for management directly and starts paying a related-party management company instead. The new management payments exceed the direct costs they replace. The study found that using a related-party management company increases management costs by an average of $1,124 per bed, a 24.6 percent increase over the mean. The researchers confirmed that these cost increases do not reflect real improvements in services. They found no evidence that using related parties improves clinical or operational outcomes. In the study's own words, these “transactions exist essentially entirely on paper.” How Widespread Is This Practice, and What Does It Hide? The study found that 77 percent of U.S. nursing homes transact with related parties, according to 2021 federal cost report data. That figure alone signals that this is not a fringe practice. It is the industry norm. The headline finding is that 68 percent of nursing home profits in 2019 were hidden through markups paid to related parties. The average facility engaged in tunneling concealed $379,382 in profits. At the high end of the distribution, the 95th percentile facility hid $1,292,657 in a single year. Those are not rounding errors. Those are deliberate financial decisions. The study explains what those hidden profits would buy. If facilities had spent their concealed profits on registered nurses instead, the mean staffing ratio across all nursing homes in the country would have increased from 0.69 hours per resident per day to 0.93 hours per resident per day. That is a 35.7 percent increase in the most skilled, most expensive, and most consequential category of nursing care. In Illinois specifically, compliance with the registered nurse component of the federal minimum staffing rule would have risen from 55.2 percent of facilities to 78.8 percent. The study also recalculates the industry's true investment returns after accounting for hidden profits. Federal cost reports imply an internal rate of return of 4.83 percent on a typical nursing home investment, well below standard investment hurdle rates. Once tunneled profits and assets are added back, the true return rises to 13.11 percent. That figure is consistent with what independent healthcare investment analysts actually report. The poverty narrative does not survive contact with the corrected data. Why Do Nursing Homes Have Every Incentive to Hide Profits? The study names four distinct financial and regulatory reasons why nursing home operators benefit from understating profitability. Each one is directly relevant to Texas. First, public reimbursement rates. Many states, including Texas, use facility cost reports when setting Medicaid reimbursement rates. When facilities overstate costs and understate profits, regulators respond by paying more. The study notes that 31 states explicitly considered facilities' reported costs when deciding Medicaid reimbursement rates, creating a direct financial incentive to inflate related-party payments. Second, lobbying against quality regulation. The industry's primary argument against staffing minimums, safety rules, and other quality mandates is that facilities cannot afford to comply. Federal advocacy groups for both for-profit and non-profit nursing homes warned that the 2023 federal minimum staffing proposal would cause facilities to close. That argument depends entirely on the accuracy of the cost report data the study found to be systematically distorted. Third, malpractice liability. This is the most relevant to families pursuing legal claims. Moving profits and assets into related entities makes the nursing home appear judgment-proof. A facility with thin reported margins and no significant real estate on its balance sheet presents a weaker target for litigation than the same facility with its true financial picture visible. The study found that shielding real estate assets from liability through related-party transactions reduces a nursing home's malpractice-related costs by 32.4 percent, approximately $25,885 per year. That is a measurable, quantified benefit from making it harder to collect on a negligence judgment. Fourth, general opacity. Even apart from those specific benefits, operators prefer to keep executive compensation, profit margins, and ownership structures away from public scrutiny. Tunneling makes cost reports opaque by design. Is Tunneling Illegal? The study is explicit that the tunneling practices it documents are “likely legal”. The transactions are disclosed in cost reports. Related-party relationships are not prohibited. The conduct the researchers describe is not fraud in the criminal sense. It is legal self-dealing that exploits gaps in regulatory oversight. That said, the study notes that accusations of tunneling have generated federal enforcement actions in some contexts. Providers reimbursed on a cost-plus basis have faced federal charges for using related-party transactions to obtain inflated Medicare reimbursements. The line between aggressive tax and liability planning and fraudulent misrepresentation of costs to a federal payer is not always clear, and the study acknowledges that the practices documented may shade into fraud in particular cases. For purposes of civil litigation, legal does not mean irrelevant. The corporate structure of a nursing home, the identity of its related-party payees, the value of assets that have been sold out of the entity, and the management fees being paid to a sister company are all discoverable and potentially probative. They bear on whether the facility's ownership made a deliberate choice to minimize visible assets and suppress profitability, which goes directly to the financial feasibility defense. What Does This Study Mean for Texas Nursing Home Neglect Cases? Texas law requires a nursing home to provide care that meets accepted professional standards. When a facility does not maintain adequate staffing and a resident is harmed, the central defense is often that the facility lacks the resources to staff at a higher level. The Gandhi and Olenski study provides academic evidence, grounded in two decades of financial data, that this defense is often a product of accounting choices rather than economic reality. The study documents that nursing homes structurally suppress visible profitability to deter malpractice claims. That is not inference. That is one of four explicitly named incentives the researchers examine, and they quantify the malpractice benefit directly. A nursing home that has moved its real estate into a related entity is conducting a documented litigation strategy, not just routine business planning. For Texas families, this means two things. First, the argument that a facility simply could not afford to staff adequately deserves direct scrutiny in any case where the facility uses related-party transactions. Second, discovery in nursing home cases should include financial relationships between the defendant facility and any commonly owned entities, particularly real estate companies and management companies. Those relationships are where the money is. Texas Health and Safety Code Chapter 242, Texas Administrative Code Chapter 554, and Texas Civil Practice and Remedies Code Chapter 74 establish the legal standards governing nursing facility care and the procedures for bringing a claim when those standards are violated. Federal requirements appear in 42 CFR Part 483. Both frameworks obligate facilities to provide sufficient care regardless of how the owner chooses to structure the entity's finances. What Should a Texas Family Do If a Loved One Was Harmed in a Nursing Home? If you believe a family member suffered harm due to inadequate staffing, neglect, or substandard care at a Texas nursing home, take these steps immediately.
We Can Help At The Borah Law Firm, PLLC, we represent patients and families across Texas in medical malpractice cases. We only handle these cases — nothing else. If you believe a loved one received substandard nursing home care, we can help you understand whether a case exists and what your options are. Contact us today for a confidential case review. Frequently Asked Questions What is the NBER study on nursing home tunneling? The study is a working paper titled Tunneling and Hidden Profits in Health Care, authored by economists Ashvin Gandhi of UCLA Anderson and Andrew Olenski of Lehigh University. Published through the National Bureau of Economic Research in March 2024 and revised in September 2025, it uses more than two decades of Illinois nursing home financial data to measure the extent to which nursing home operators move profits and assets into related companies to hide them from regulators, legislators, and malpractice claimants. What is a related-party transaction in a nursing home? A related-party transaction occurs when a nursing home pays for goods or services from another company that shares the same ownership. Common examples include rent paid to a landlord entity owned by the same operator, and management fees paid to a management company owned by the same operator. The Gandhi and Olenski study found that 77 percent of U.S. nursing homes engaged in related-party transactions as of 2021, and that the payments made in these transactions substantially exceed the actual cost of the goods and services provided. Can the financial structure of a nursing home affect a malpractice case in Texas? Yes. A nursing home's financial structure, including its related-party relationships, the transfer of real estate to sister entities, and management fee payments to commonly owned companies, is relevant to litigation in at least two ways. First, it bears on the financial feasibility defense, which is the argument that the facility could not afford to staff adequately. Second, finding all entities that received value from the facility is necessary to find assets that may be available to satisfy a judgment. Discovery in Texas nursing home cases should include requests for the facility's cost reports, related-party disclosures, and ownership structure documentation. Does the NBER study cover Texas nursing homes specifically? The empirical data in the Gandhi and Olenski study comes from Illinois, which has required nursing homes to report related-party transactions for more than two decades. The researchers note that related-party transactions are common across the entire U.S. nursing home industry based on federal cost report data. The study's findings on the structure and incentives of tunneling apply to the industry nationally. Texas nursing homes file the same federal cost reports and operate under the same ownership structures documented in the study. How do I find out if a Texas nursing home uses related-party transactions? Federal cost reports filed by Medicare and Medicaid-certified nursing homes are publicly available through CMS. Those reports include disclosures of related-party transactions. ProPublica's Nursing Home Inspect tool at projects.propublica.org/nursing-homes provides searchable access to CMS data including inspection records, deficiency citations, staffing levels, and ownership information. For detailed financial records, including line-item related-party disclosures, a formal records request or discovery process may be required. About the Author: J.T. Borah is a Texas medical malpractice attorney and founding attorney of The Borah Law Firm, PLLC, in Austin, Texas. His practice is limited exclusively to medical malpractice cases involving hospitals, nursing homes, and other medical institutions. He has been recognized as a Texas Super Lawyer. He is often asked to lecture at legal seminars on medical malpractice issues and has lectured to attorneys from 18 states. AI writing tools assisted Mr. Borah in preparing this article. All legal standards, citations, and factual claims were reviewed by Mr. Borah as a licensed Texas attorney. This article is for general informational purposes only and does not constitute legal advice. Reading this article does not create an attorney-client relationship.  The Ensign Group already operates nursing homes in Texas. It is the largest operator of skilled nursing facilities in the country, with 334 CMS-certified locations across 17 states, according to April 2026 CMS data. On April 30, 2026, Ensign announced the acquisition of 17 additional Texas facilities in Dallas, Houston, Kerrville, Fort Worth, San Antonio, and other cities, effective May 1, 2026. The company is not entering this state. It is growing its footprint here.
A five-month investigation published June 8, 2026, by Hunterbrook Media found that Ensign's growth model is built on a specific pattern: buy struggling nursing homes, cut nursing staff hours, pocket the savings, and inflate self-reported quality metrics. Patients died. Federal inspectors documented maggot infestations inside residents' bodies. A nonverbal Alzheimer's patient was found covered in ants at an Ensign facility in Texas, an infestation her family discovered, not the staff. That Texas facility is Park Village Healthcare and Rehabilitation, located at 207 E Parkerville Rd, DeSoto, TX 75115. According to ProPublica Nursing Home Inspect data current as of March 2026, Park Village has accumulated 52 total deficiencies and $266,405 in total fines over the past three years. Nurse turnover stands at 68.6 percent. The state average is 51.5 percent. Texans who are placing a loved one in a nursing home need to understand what the Ensign record actually looks like, not what Ensign tells investors it looks like. What Did the Hunterbrook Investigation Find About Ensign? Hunterbrook Media, an investigative news organization affiliated with a short-selling investment fund, published its findings on June 8, 2026, after a five-month examination of millions of CMS data points, thousands of pages of documents, and interviews with attorneys, academics, healthcare professionals, former employees, residents, and family members. The core finding: Ensign's profits are substantially tied to providing less nursing care than its patients require, according to the investigation. Hunterbrook calculated that between July and November 2024, Ensign residents received more than 5 million fewer hours of nursing care than their documented medical acuity required. Using Ensign's own payroll cost data, Hunterbrook estimated this gap saved Ensign approximately $161 million during that five-month window, roughly $386 million annualized. Ensign's net income for all of 2024 was $298 million. The investigation's findings are organized around four structural practices. First, understaffing. Federal law under 42 CFR §483.35 requires Medicare and Medicaid-funded facilities to maintain sufficient nursing staff to meet each resident's needs. Texas mirrors this obligation under 26 Tex. Admin. Code §554.1001. Hunterbrook found that Ensign facilities violated state minimum staffing floors in California, Kansas, Tennessee, and Washington on more than 18,000 cumulative days from 2020 through 2025. Second, metric manipulation. Ensign's most-publicized quality scores come from self-reported data with no independent verification requirement. Hunterbrook separated CMS metrics into three tiers: independently verified by unannounced inspectors, self-reported but auditable via payroll records, and self-assessed with no documentation requirements. On independently verified metrics, Ensign performed worse than the national average. On the self-reported metrics it touts to investors, it outperformed by as much as 24 percent. Third, tunneling. Ensign paid more than $339 million in 2024 to entities it also owns or controls, including landlords, insurers, and management companies. That figure exceeded Ensign's total reported net income that year. A 2024 congressional letter cited this practice as a tactic to conceal profit by making individual nursing homes appear financially strapped. Fourth, acquisition-driven deterioration. Hunterbrook tracked 161 facilities before and after Ensign acquired them, comparing against roughly 15,000 other nursing facilities nationally, and found that total nursing hours fall after acquisition and continue falling over time. Registered nurse hours, which represent the most skilled and most expensive category of care, drop most sharply. What Is Happening at Park Village Healthcare and Rehabilitation in DeSoto, Texas? Park Village Healthcare and Rehabilitation, 207 E Parkerville Rd, DeSoto, TX 75115, is an Ensign-affiliated facility, listed under Ensign Services Inc. in CMS ownership records. According to ProPublica Nursing Home Inspect data current as of March 2026, the facility's record includes the following. Total deficiencies: 52. Total fines over three years: $266,405. Nurse turnover: 68.6 percent, compared to a state average of 51.5 percent. Nurse hours per resident per day: 3.28, below the 3.48 hours CMS research determined was needed to meet residents' actual acuity requirements. The facility's inspection history includes multiple Immediate Jeopardy citations. On July 23, 2025, CMS issued an Immediate Jeopardy citation under Tag F0925, failure to maintain a pest control program, paired with a $17,345 fine. The Hunterbrook investigation reported that a nonverbal resident with Alzheimer's disease was found covered in ants at a DeSoto Ensign facility in July 2025, with bites across her face, neck, legs, and eyes swollen shut. Her family discovered the infestation. Staff did not. On November 15, 2025, CMS issued two additional Immediate Jeopardy citations at Park Village: Tag F0600, failure to protect residents from abuse, neglect, and exploitation, and Tag F0610, failure to respond appropriately to alleged violations. On October 1, 2025, the facility received a $128,620 fine tied to a separate abuse citation. The March 24, 2025, standard inspection resulted in a K-level citation, the highest scope/severity possible, for Tag F0880, failure to implement an infection prevention and control program, along with a $62,762 fine. CMS characterizes Immediate Jeopardy as a situation in which the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. That is the verified record at this one Ensign facility in Texas. The Hunterbrook investigation identified Park Village by name in its analysis of Ensign's star rating manipulation, noting that the facility carries five stars on self-reported quality measures while carrying one-star ratings on health inspections and staffing, the metrics with independent verification. What Texas Facilities Did Ensign Just Acquire? According to Ensign's April 30, 2026 investor press release, the following skilled nursing facilities became Ensign-operated as of May 1, 2026: Country Village Care / Country Village Senior Living, 136 skilled nursing beds with assisted living and memory care, Angleton, La Dora Nursing and Rehabilitation Center, 62 beds, Bedford, Mustang Park Therapy and Living Center, 120 beds, Carrollton, TruCare Living Centers Columbus, 104 beds, Columbus, Southern Oaks Therapy and Living Center, 150 beds, Dallas, Mallard Creek Therapy and Living Center, 120 beds, Fort Worth, Eagle Crest Rapid Recovery, 125 beds, Houston, Falcon Point Post Acute, 130 beds, Katy, Hilltop Village Nursing and Rehabilitation Center, 150 beds, Kerrville, River Hills Health and Rehabilitation Center, 150 beds, Kerrville, Parks Health Center / Parks Assisted Living Center, 90 skilled nursing beds with assisted living and independent living, Odessa, TruCare Living Centers Palestine, 120 beds, Palestine, Harbor Valley Health and Rehabilitation, 120 beds, San Antonio, River Bend Healthcare, 115 beds, Seguin, TruCare Living Centers Selma, 128 beds, Selma Willow Creek Lodge, 135 beds, Tomball, and Willow Park Rehabilitation and Care Center, 125 beds, Willow Park. These facilities were previously under different operators. The Hunterbrook investigation found that nursing hours fall at facilities after Ensign takes them over, and that the staffing decline widens over time. Ensign already operates other Texas nursing homes, and the same pattern applies to those. If you have a family member at any of these newly acquired facilities, or at any existing Ensign-operated location in Texas, you are dealing with a company whose national record is documented above. Did Ensign Respond to the Investigation? Ensign did not respond to Hunterbrook's repeated requests for comment. The company's silence is itself a documented finding in the investigation. Ensign CEO Barry Port did speak to The Arizona Republic in 2023, stating that staffing decisions are made at the individual facility level. The Hunterbrook investigation found that assertion contradicted by Ensign's own 10-K filings, which describe centralized software systems installed at each facility to monitor and increase billing, and by earnings call statements in which Port cited access to patient-level data and facility-level decision-making. Ensign has settled federal fraud claims twice before. In one settlement, Ensign paid $48 million to resolve allegations that six California facilities billed Medicare for unnecessary treatment. In a second settlement, Ensign paid more than $47 million to resolve claims involving alleged illegal kickbacks for patient referrals. Those settlements did not include admissions of liability. What Does Texas Law Require of Nursing Homes? The Texas Health and Safety Code Chapter 242, Texas Administrative Code Chapter 554, and Texas Civil Practice and Remedies Code Chapter 74 establish the legal standards governing nursing facilities in Texas. The parallel federal requirements for Medicare and Medicaid-participating facilities appear in 42 CFR Part 483. Both frameworks require that facilities provide each resident with the level of care and services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Under 26 Tex. Admin. Code §554.1001, Texas requires that staffing be sufficient to meet resident needs. There is no fixed numeric hourly floor under Texas law that matches the federal standard, but the sufficiency requirement is enforceable. CMS research concluded that 3.48 nursing hours per resident per day represents the minimum needed to meet a typical resident's acuity level. Park Village Healthcare is currently providing 3.28 hours per resident per day. Texas residents in nursing facilities also have rights under Texas Health and Safety Code §242.501 et seq., including the right to be free from neglect, abuse, and exploitation, and the right to receive care that meets accepted professional standards. When a facility's conduct falls below those standards and a resident is harmed, that may give rise to a medical malpractice claim under Texas law. Texas Civil Practice and Remedies Code §74.001 et seq. governs medical malpractice claims in this state. Nursing home negligence claims are subject to specific procedural requirements, including a 180-day notice period and the requirement to provide a supporting expert report. What Should a Texas Family Do If They Suspect Nursing Home Neglect? If you believe a family member has been harmed by nursing home neglect, take these steps immediately.
We Can Help At The Borah Law Firm, PLLC, we represent patients and families across Texas in medical malpractice cases. We only handle these cases — nothing else. If you believe a loved one received substandard nursing home care, we can help you understand whether a case exists and what your options are. Contact us today for a confidential case review. Frequently Asked Questions Is the Ensign Group a licensed nursing home operator in Texas? Yes. Ensign Group-affiliated entities have operated nursing facilities in Texas for years, and as of May 1, 2026, the company expanded its Texas footprint by 17 additional facilities according to its own investor press release. What is an Immediate Jeopardy citation in a nursing home? An Immediate Jeopardy citation is issued by CMS when a nursing facility's noncompliance with federal standards has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. It is the most serious citation level CMS issues. Park Village Healthcare and Rehabilitation in DeSoto, Texas, has received multiple Immediate Jeopardy citations since 2023, verified by ProPublica Nursing Home Inspect data. Can I sue a nursing home in Texas for neglect? Yes. Texas law permits claims against nursing homes and their parent companies for negligence and other causes of action when substandard care causes injury or death. These claims are subject to Texas Civil Practice and Remedies Code Chapter 74, which imposes specific procedural requirements including mandatory pre-suit notice and an expert report. What is tunneling in the nursing home context? Tunneling refers to the practice by which a nursing home pays other entities it controls, such as a landlord, insurer, or management company, at rates that may exceed fair market value. This practice moves revenue out of the nursing home and into affiliated entities, making the nursing home appear financially strapped while the parent company reports substantial profits. A 2024 congressional letter described this as a tactic nursing home chains use to conceal profit from regulators. How do I get nursing home inspection records in Texas? CMS publishes inspection records for all Medicare and Medicaid-certified nursing homes at Medicare.gov Care Compare. ProPublica's Nursing Home Inspect tool at projects.propublica.org/nursing-homes aggregates and presents the same CMS data in a searchable format. Both sources are publicly available. About the Author: J.T. Borah is a Texas medical malpractice attorney and founding attorney of The Borah Law Firm, PLLC, in Austin, Texas. His practice is limited exclusively to medical malpractice cases involving hospitals, nursing homes, and other medical institutions. He has been recognized as a Texas Super Lawyer. He is often asked to lecture at legal seminars on medical malpractice issues and has lectured to attorneys from 18 states. AI writing tools assisted Mr. Borah in preparing this article. All legal standards, citations, and factual claims were reviewed by Mr. Borah as a licensed Texas attorney. This article is for general informational purposes only and does not constitute legal advice. Reading this article does not create an attorney-client relationship.  On March 19, 2026, federal surveyors cited two Texas nursing homes for a combined four Immediate Jeopardy-level deficiencies. The first facility is Liberty Health Care Center, located at 1206 North Travis Street in Liberty, Texas, a small city northeast of Houston in Liberty County. The second is The Heights of League City, located at 2620 West Walker in League City, Texas, in Galveston County southeast of Houston. Neither facility is connected to the other in any way the public record shows. Yet on the same calendar date, federal complaint inspections at both facilities produced the same result: Immediate Jeopardy findings for failures to follow physician orders and protect residents from harm. That pattern is worth examining. It is not a coincidence that demands a conspiracy theory. It is a data point that raises a harder question, whether these failures reflect something systemic about how Texas nursing homes are staffed, trained, and supervised. Both facilities' inspection records are verified directly from ProPublica's Nursing Home Inspect database, which draws from federal Centers for Medicare and Medicaid Services survey data. All facility names, addresses, citation dates, deficiency descriptions, federal tag numbers, and fine amounts cited in this article are directly observed from those records. The March 19, 2026 Citations: What the Records Show The following table presents the four citations issued on March 19, 2026, as documented in the ProPublica database.   Both Liberty Health Care Center citations were issued through a single complaint-driven inspection report, meaning someone filed a complaint that triggered the investigation. The total fine assessed for that report was $24,845. Both Heights of League City citations were similarly issued through a single complaint-driven inspection, with a fine of $18,860.
What These Federal Deficiency Codes Actually Require Nursing Homes to Do F0684 — Failure to Follow Treatment Orders Federal tag F0684 corresponds to 42 CFR §483.25(i), which requires nursing facilities to provide care and services consistent with the care plan, the attending physician's orders, and the resident's preferences and goals. When a facility receives an F0684 citation at Immediate Jeopardy severity, it means surveyors found that the facility's failure to follow orders created a situation likely to cause, or that already caused, serious injury, serious harm, or death to a resident. This is not a paperwork deficiency. It means a physician wrote orders for a patient's care, the nursing home did not follow them, and a person was placed in serious danger as a result. F0580 — Failure to Notify Resident, Physician, and Family Federal tag F0580 corresponds to 42 CFR §483.10(g)(14), which requires facilities to immediately notify the resident, the resident's physician, and a family member or the resident's legal representative when there is a change in the resident's condition, including an accident, an injury, a significant medical change, a change in room assignment, or a transfer or discharge decision. An Immediate Jeopardy finding under F0580 means the facility's failure to provide that notification placed a resident in serious danger. Someone fell, or declined, or experienced a medical event, and the people responsible for that resident's welfare were not told. F0689 — Failure to Prevent Accidents and Provide Supervision Federal tag F0689 corresponds to 42 CFR §483.25(d), which requires each facility to ensure that the resident environment remains as free of accident hazards as possible, and that each resident receives adequate supervision and assistance to prevent accidents. An Immediate Jeopardy finding under this tag means that a resident was exposed to a serious risk of harm or death because the facility failed to identify a hazard, failed to supervise adequately, or both. Liberty Health Care Center: A Pattern Before March 2026 The March 2026 citations were not Liberty Health Care Center's first serious federal violations. According to the facility's ProPublica profile, the facility received three Immediate Jeopardy citations in a single complaint inspection on May 9, 2025, less than a year before the March 2026 findings. Those May 2025 citations included: failure to develop and implement policies to prevent abuse, neglect, and theft (F0607, severity J), failure to develop and implement a complete care plan (F0656, severity J), and failure to ensure the facility is free from accident hazards and provides adequate supervision (F0689, severity J). That inspection resulted in a $197,285 fine. Across the three-year penalty window tracked by CMS, Liberty Health Care Center has accumulated $222,000 in total fines. The facility's nurse turnover rate is 76.9 percent, compared to a Texas state average of 53.9 percent. That figure is directly observed from the ProPublica data. The relationship between high turnover and citation rates is an inference, not a finding in the public record, but the gap between this facility's turnover and the state average is significant and documented. The Heights of League City: Five Rounds of Serious Citations in Two Years The Heights of League City has accumulated one of the more significant recent citation histories in the ProPublica Texas database. The March 2026 report is the fifth documented instance of Immediate Jeopardy-level findings at this facility since May 2024. The table below presents the verified record, drawn directly from the facility's ProPublica profile. Several observations from that record warrant attention. First, the F0580 notification failure, the same deficiency cited in March 2026 at Immediate Jeopardy severity, previously appeared at this facility in September 2023 at G severity and again in January 2025 at K severity. The same failure, at three increasing severity levels, across three separate inspection reports. Second, the F0689 accident supervision failure appeared in September 2023, July 2025, and as part of the January 2025 multi-finding report. The Heights of League City's total fines over the three-year CMS window are $142,000. Its nurse turnover rate is 67.5 percent, against the state average of 53.9 percent. Both turnover figures at both facilities exceed the state average by a substantial margin. Again, the causal link between turnover and the citation patterns is an inference. The data is documented but the causation is not established by the public record alone. What These Two Facilities Tell Us About a Larger Problem The fact that four Immediate Jeopardy citations were issued to two geographically unrelated, separately owned Texas nursing homes on the same date is not by itself evidence of systemic failure. It could be coincidence. Inspectors operate on complaint-driven timelines, and complaints can cluster by date for reasons unrelated to facility-wide trends. What makes this pattern worth examining is what the citations have in common. Both facilities were cited for F0684, failure to follow physician orders. Both had prior histories of the same or related deficiencies. Both had nurse turnover rates materially above the state average. And both received complaint-driven reports rather than routine standard inspections, which means in each case, someone contacted the government to report a problem before surveyors arrived. When a nursing home fails to follow a physician's order at Immediate Jeopardy severity, the failure is not a clerical error. It is a breakdown in the systems the facility uses to track, communicate, and execute care directives for vulnerable people. Understaffing and high turnover are the most commonly identified contributors to that kind of failure in federal enforcement literature, but the public CMS record documents the result, not the cause. The cause is what litigation uncovers. What Texas Families Should Do If They Suspect Nursing Home Negligence If your family member is a current or former resident of either of these facilities, or any Texas nursing home where you suspect a failure of care, the following steps apply.
We Can Help At The Borah Law Firm, PLLC, we represent patients and families across Texas in medical malpractice cases involving nursing homes, hospitals, and other institutional defendants. We handle cases on a contingency basis, you pay no attorney's fees unless we recover for you. If you believe a loved one received substandard nursing home care, we can help you understand whether a case exists and what your options are. Contact us today for a confidential case review. Frequently Asked Questions What does federal tag F0684 mean and why does it matter in a nursing home negligence case? F0684 is the federal deficiency code for failure to provide treatment and care according to physician orders, the resident's preferences, and the resident's goals. It corresponds to 42 CFR §483.25(i). When cited at Immediate Jeopardy severity, it means the facility failed to follow a physician's written orders in a way that placed a resident at serious risk of harm or death. In a negligence case, that citation is government documentation that the facility's own practices fell below a federally mandated standard of care. What does federal tag F0580 mean and why does it matter? F0580 is the federal deficiency code for failure to immediately notify the resident, the resident's physician, and a family member of situations affecting the resident. It corresponds to 42 CFR §483.10(g)(14). At Immediate Jeopardy severity, it means the facility's failure to notify placed a resident in serious danger. Beyond the legal significance, an F0580 citation at IJ severity means families were kept in the dark while a family member was at risk. How do I find out if a Texas nursing home has a history of serious violations? The most direct resource is ProPublica Nursing Home Inspect at projects.propublica.org/nursing-homes. It draws from CMS survey data and shows each facility's citation history, fine history, staffing levels, turnover rates, and ownership. CMS Care Compare at medicare.gov/care-compare provides the underlying inspection reports in PDF form. Both are free and publicly accessible. Can a nursing home's citation history be used as evidence in a Texas negligence case? A federal deficiency citation is not a civil judgment. It does not automatically establish liability. To prevail in a Texas nursing home negligence case, a Plaintiff must prove the applicable standard of care, that the facility deviated from it, and that the deviation caused actual damages. A citation, particularly an Immediate Jeopardy finding, is relevant evidence that the facility's practices fell below federally mandated standards at the time of the survey. It can support, but cannot substitute for, a complete liability case. How long does a family have to file a nursing home negligence lawsuit in Texas? Texas Civil Practice and Remedies Code §74.251 imposes a two-year statute of limitations on health care liability claims. The clock generally runs from the date of the negligent act or omission, or the date the Claimant discovered or should have discovered the harm. Missing the deadline forfeits the claim entirely. Consulting an attorney promptly is essential. About the Author: J.T. Borah is a Texas medical malpractice attorney and founding attorney of The Borah Law Firm, PLLC, in Austin, Texas. His practice is limited exclusively to medical malpractice cases involving hospitals, nursing homes, and other medical institutions. He has been recognized as a Texas Super Lawyer and holds Top 10, Top 25, and Top 100 designations from the Nursing Home Trial Lawyers Association. He is often asked to lecture at legal seminars on medical malpractice issues. AI writing tools assisted Mr. Borah in preparing this article. All legal standards, citations, and factual claims were reviewed by Mr. Borah as a licensed Texas attorney. This article is for general informational purposes only and does not constitute legal advice. Reading this article does not create an attorney-client relationship. Legal Disclaimer: The Borah Law Firm, PLLC, represents Plaintiffs in Texas medical malpractice cases. This article discusses publicly available enforcement data and general legal principles. Past results do not guarantee future outcomes. |
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