Cycle 1
Health 2024-11-06 · Fire 2024-11-06
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Texarkana, TX
Cornerstone Retirement Community
2-star overall rating with 2-star inspections with $39,764 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4100 Moores Ln, Texarkana, TX
(903) 832-5515
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
36
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Methodist Retirement Communities
Operator or chain grouping
Approved since
2014-04-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 4 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
0.92
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,806
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.96
Baseline 23.81% · Performance 22.14% · Measure score 1.96 · Achievement 0 · Improvement 1.96
Healthcare-associated infections
1.27
Baseline 5.17% · Performance 7.46% · Measure score 1.27 · Achievement 1.27 · Improvement 0
Total nurse turnover
2.53
Baseline 51.28% · Performance 53.33% · Measure score 2.53 · Achievement 2.53 · Improvement 0
Adjusted total nurse staffing
4.49
Baseline 4.36 hours · Performance 4.36 hours · Measure score 4.49 · Achievement 4.49 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.76% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 6.92% · Lower 95% interval 6.83% |
| Discharge to community | 59.58% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 56% · Lower 95% interval 49.03% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.65% |
95.27%
3.4 pts better
|
Numerator 73 · Denominator 74 |
| Falls with major injury | 2.7% |
0.77%
1.9 pts worse
|
Numerator 2 · Denominator 74 |
| Discharge self-care score | 52.73% |
53.69%
1 pts worse
|
Numerator 29 · Denominator 55 |
| Discharge mobility score | 63.64% |
50.94%
12.7 pts better
|
Numerator 35 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 6.76% |
2.29%
4.5 pts worse
|
Numerator 5 · Denominator 74 · Adjusted rate 8.38% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 6.94% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 5.56% |
8.2%
2.6 pts worse
|
Numerator 4 · Denominator 72 |
| Staff flu vaccination coverage | 72.97% |
42%
31 pts better
|
Numerator 54 · Denominator 74 |
| Discharge function score | 56.36% |
56.45%
0.1 pts worse
|
Numerator 31 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 7.69% |
25.2%
17.5 pts worse
|
Numerator 3 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| 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 | 3.5% |
3.3%
0.2 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.9% · Q3 3.6% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
2.7%
1.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 25.7% |
3.3%
22.4 pts worse
|
5.4%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
18.9%
3.4 pts better
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
10.8%
6.4 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.2% · 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 | 39.9% |
15.4%
24.5 pts worse
|
16.3%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
16.1%
4.9 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.5%
0.1 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
15.0%
11.3 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 28.0% · Q3 26.2% · Q4 15.4% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.2%
1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.1% · Q3 7.7% · Q4 5.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
89.7%
3.6 pts better
|
81.7%
11.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 91.7% · Q3 90.9% · Q4 98.0% · 4Q avg 93.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
12.0%
4.9 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 0.0% · Q4 3.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
88.0%
5.1 pts better
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.3% |
25.9%
7.4 pts worse
|
23.9%
9.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.3% · Observed 28.9% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-03 · Fire 2022-08-03
4 health deficiencies
Top issue: Nutrition and Dietary (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
2024-11-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-26
Inspection history
Recent health citations
J · Immediate jeopardy
2024-11-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-11-06
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 2024-11-26
E · Potential for more than minimal harm
2024-11-06
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 2024-11-26
E · Potential for more than minimal harm
2024-11-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-06
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-11-06
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 2024-11-26
D · Potential for more than minimal harm
2024-11-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-11-06
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 2024-11-26
F · Potential for more than minimal harm
2023-09-20
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 2023-10-10
D · Potential for more than minimal harm
2023-09-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-20
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-10-10
E · Potential for more than minimal harm
2022-08-03
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 2022-09-01
D · Potential for more than minimal harm
2022-08-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-08-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-08-03
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-09-01
Penalties and ownership
What sits behind the stars
$39,764
2024-11-06
Fine
Fine · fine $39,764
Fine
Ownership
Mrc Cornerstone
5% Or Greater Direct Ownership Interest · Organization
The Aldersgate Trust
5% Or Greater Indirect Ownership Interest · Organization
Baggett, Alyce
Corporate Director · Individual
Besser, Alicia
Corporate Director · Individual
Brown, Alan
Corporate Director · Individual
Brown, Alan
Corporate Officer · Individual
Bunch, James
Corporate Director · Individual
Conger, Dale
Corporate Director · Individual
Currie, Matthew
Corporate Officer · Individual
Elmore, Sydney
Operational/Managerial Control · Individual
Gilts, Kip
Corporate Director · Individual
King, William
Corporate Director · Individual
Koerner, William
Corporate Director · Individual
Lewis, Charles
Operational/Managerial Control · Individual
Malone-Wardley, Romonica
Corporate Director · Individual
Morgan, Richard
Corporate Director · Individual
Partin, Todd
Operational/Managerial Control · Individual
Simmons, Ed
Corporate Director · Individual
Stephens, Donald
Corporate Officer · Individual
Thomas, Amy
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Mortgage Interest · Organization
Watson, Frankie
Corporate Director · Individual
Williamson, Billy
Corporate Director · Individual
Woodward, Walter
Corporate Director · Individual
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