Cycle 1
Health 2025-05-29 · Fire 2025-05-29
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Temple, TX
Cornerstone Gardens Llp
3-star overall rating with 3-star inspections with $15,757 in total fines with 6 recent health deficiencies
763 Marlandwood Rd, Temple, TX
(254) 771-5950
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-10-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.34
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.12
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
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
934
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0169
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.10
Baseline 15.66% · Performance 18.14% · Measure score 7.10 · Achievement 7.10 · Improvement 0
Healthcare-associated infections
9.22
Baseline 4.36% · Performance 5.08% · Measure score 9.22 · Achievement 9.22 · Improvement 0
Total nurse turnover
4.94
Performance 43.48% · Measure score 4.94 · Achievement 4.94 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.52
Baseline 3.97 hours · Performance 4.08 hours · Measure score 3.52 · Achievement 3.52 · Improvement 0.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.82% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 236 · Observed rate 5.51% · Lower 95% interval 6.11% |
| Discharge to community | 55.93% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 231 · Observed rate 57.14% · Lower 95% interval 50.15% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.23% |
95.27%
3 pts better
|
Numerator 111 · Denominator 113 |
| Falls with major injury | 0.88% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 113 |
| Discharge self-care score | 38.68% |
53.69%
15 pts worse
|
Numerator 41 · Denominator 106 |
| Discharge mobility score | 18.87% |
50.94%
32.1 pts worse
|
Numerator 20 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 7.08% |
2.29%
4.8 pts worse
|
Numerator 8 · Denominator 113 · Adjusted rate 7.22% |
| Healthcare-associated infections requiring hospitalization | 5.08% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 0.9% · Lower 95% interval 2.67% |
| Staff COVID-19 vaccination coverage | 0.59% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 170 |
| Staff flu vaccination coverage | 96.08% |
42%
54.1 pts better
|
Numerator 98 · Denominator 102 |
| Discharge function score | 23.58% |
56.45%
32.9 pts worse
|
Numerator 25 · Denominator 106 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.25% |
96.28%
About the same
|
Numerator 77 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 1.61% |
25.2%
23.6 pts worse
|
Numerator 1 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.1
1.7 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.7% |
97.1%
18.4 pts worse
|
93.4%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.1% · Q2 76.1% · Q3 81.2% · Q4 78.3% · 4Q avg 78.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
97.9%
0.8 pts worse
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.9% |
3.3%
4.6 pts worse
|
3.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 9.0% · Q3 9.4% · Q4 7.2% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
2.7%
3.1 pts worse
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 4.5% · Q3 3.3% · Q4 6.2% · 4Q avg 5.8% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 1.9% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.8% |
18.9%
4.9 pts worse
|
19.6%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 22.6% · Q3 28.0% · Q4 25.5% · 4Q avg 23.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
10.8%
5.1 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 8.7% · Q3 2.4% · Q4 2.3% · 4Q avg 5.7% · 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 | 21.2% |
15.4%
5.8 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 21.1% · Q3 9.7% · Q4 30.5% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.1% |
16.1%
2 pts worse
|
14.9%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 21.3% · Q3 24.4% · Q4 9.6% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
0.5%
2.6 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.4% · Q3 6.6% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.0% · Q4 1.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
15.0%
7.3 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 31.1% · Q3 20.5% · Q4 16.1% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
4.2%
3.3 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.9% · Q3 10.0% · Q4 9.8% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.4% |
89.7%
21.3 pts worse
|
81.7%
13.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.6% · Q2 67.3% · Q3 61.9% · Q4 68.3% · 4Q avg 68.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
12.0%
6.5 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 4.8% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.8% |
88.0%
39.2 pts worse
|
79.7%
30.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
25.9%
1.7 pts better
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 21.9% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-27 · Fire 2024-04-27
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-10
E · Potential for more than minimal harm
2024-04-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-10
E · Potential for more than minimal harm
2024-04-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-02-10
E · Potential for more than minimal harm
2024-04-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-21
D · Potential for more than minimal harm
2024-04-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-04-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-07
C · Minimal harm
2023-03-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-29
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 2025-06-29
E · Potential for more than minimal harm
2025-05-29
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 2025-06-13
D · Potential for more than minimal harm
2025-05-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
J · Immediate jeopardy
2024-04-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-28
J · Immediate jeopardy
2024-04-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-28
E · Potential for more than minimal harm
2024-04-27
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 2024-05-10
D · Potential for more than minimal harm
2024-04-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-27
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-27
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 2024-05-10
D · Potential for more than minimal harm
2023-11-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-31
Penalties and ownership
What sits behind the stars
$15,757
2024-04-27
Fine
Fine · fine $15,757
Fine
Ownership
Burmont, Inc.
5% Or Greater Direct Ownership Interest · Organization
Arnold, Jason
Corporate Officer · Individual
Burmont, Inc.
Limited Partnership Interest · Organization
Daniel, Pamela
W-2 Managing Employee · Individual
Green, Aval-Na'ree
Contracted Managing Employee · Individual
Holler, Ryan
W-2 Managing Employee · Individual
Montgomery, Mitchell
Corporate Officer · Individual
Montgomery, Raymond
Corporate Officer · Individual
Oak Management
General Partnership Interest · Organization
Nearby options
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Avir at Temple East
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Avir at Temple West
Temple, TX
1-star overall rating with 1-star inspections with abuse icon flag with $7,257 in total fines with 4 recent health deficiencies
#3
Morada Temple
Temple, TX
3-star overall rating with 3-star inspections with $14,722 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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