Cycle 1
Health 2024-12-13 · Fire 2024-12-13
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Glen Rose, TX
Cherokee Rose Nursing And Rehabilitation
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
203 Gibbs Blvd, Glen Rose, TX
(254) 897-7361
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1992-03-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.30
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.64
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.91
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.43
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,478
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.05
Baseline 44.44% · Performance 51.22% · Measure score 3.05 · Achievement 3.05 · Improvement 0
Adjusted total nurse staffing
1
Baseline 3.23 hours · Performance 3.36 hours · Measure score 1 · Achievement 1 · Improvement 0.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 6.28% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.55% |
95.27%
1.3 pts better
|
Numerator 28 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 6.9% |
2.29%
4.6 pts worse
|
Numerator 2 · Denominator 29 · Adjusted rate 6.45% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | 37.17% |
42%
4.8 pts worse
|
Numerator 42 · Denominator 113 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.6% |
2.7%
8.9 pts worse
|
11.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 5.0% · Q3 8.3% · Q4 18.2% · 4Q avg 11.6% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
3.3%
0.3 pts worse
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.9% · Q3 6.5% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
18.9%
3.9 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 16.7% · Q3 9.7% · Q4 16.7% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
10.8%
2 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 7.4% · Q3 7.4% · Q4 6.7% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.8% |
15.4%
0.6 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 8.5% · Q3 26.1% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
16.1%
4.6 pts better
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.1% · Q3 10.0% · Q4 11.1% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.7% |
15.0%
5.3 pts better
|
19.8%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 5.9% · Q3 0.0% · Q4 7.7% · 4Q avg 9.7% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.2%
0.5 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 9.8% · Q3 2.7% · Q4 2.1% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
89.7%
0.5 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 89.5% · Q3 91.9% · Q4 80.0% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.7% |
12.0%
16.7 pts worse
|
12.0%
16.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 29.6% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
88.0%
6.6 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 46.6% |
25.9%
20.7 pts worse
|
23.9%
22.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 46.6% · Observed 40.7% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-08-30 · Fire 2022-08-30
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-01-04
F · Potential for more than minimal harm
2024-12-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-04
E · Potential for more than minimal harm
2024-12-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-04
F · Potential for more than minimal harm
2023-10-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-06
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-08-07
E · Potential for more than minimal harm
2024-12-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-12-13
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-12-13
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-12-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-12-13
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-12-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-12-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-14
D · Potential for more than minimal harm
2023-10-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-25
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-25
F · Potential for more than minimal harm
2022-08-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-31
E · Potential for more than minimal harm
2022-08-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-08-31
E · Potential for more than minimal harm
2022-08-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-23
Penalties and ownership
What sits behind the stars
Ownership
Honor X Enterprises, LLC
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
5% Or Greater Indirect Ownership Interest · Individual
Blake, Malisa
5% Or Greater Indirect Ownership Interest · Individual
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Creative Solutions In Healthcare Inc
Operational/Managerial Control · Organization
Huggins, Linda
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Glen Rose Nursing and Rehab Center
Glen Rose, TX
3-star overall rating with 2-star inspections with abuse icon flag with $17,128 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Granbury Rehab & Nursing
Granbury, TX
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Harbor Lakes Nursing And Rehabilitation Center
Granbury, TX
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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