Based on interview and record review the facility failed to develop, implement, and maintain an effective compliance and ethics program that is likely to be effective in preventing and detecting criminal, civil, and administrative violations and promoting quality of care in that: The facility failed to conduct effective training and education to staff. The facility failed to have a designated compliance liaison. The facility failed to have a designated compliance officer that was not a subordinate to a chief operating officer (Regional Director of Operations). The facility failed to have a compliance committee. The facility failed to promote and create an environment where staff are comfortable reporting and talking to State without fear of retaliation. …
F895 citations in Texas
Administration Deficiencies
Have a Compliance and Ethics Program.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Texas cites F895 less often than its own record predicts
0.80 times the national share — cited less often here than elsewhere.
Of every deficiency written in Texas in 2024, this is the portion that was F895.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Texas surveyors wrote
F895 findings written in Texas, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
What else Texas surveyors cite →
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