5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Emory, TX
4-star overall rating with 4-star inspections with $11,148 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
983 N Texas Street, Emory, TX
(903) 473-3752
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
68
Certified beds
Average residents
42
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-07-22
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
RN hours / resident day
0.35
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.11
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 13.33% · Lower 95% interval 6.18% |
| 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 | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
97.1%
3 pts worse
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 92.1% · Q3 94.6% · Q4 97.6% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
97.9%
5 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.3%
1.9 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.6% · Q3 5.4% · Q4 7.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 0.7% |
3.3%
2.6 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.0% |
18.9%
12.1 pts worse
|
19.6%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 34.3% · Q3 35.3% · Q4 32.5% · 4Q avg 31.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
10.8%
0.9 pts worse
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.0% · Q3 10.7% · Q4 6.1% · 4Q avg 11.7% · 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 | 46.1% |
15.4%
30.7 pts worse
|
16.3%
29.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.3% |
16.1%
16.2 pts worse
|
14.9%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 32.3% · Q3 21.9% · Q4 33.3% · 4Q avg 32.3% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 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 | 13.4% |
15.0%
1.6 pts better
|
19.8%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 10.3% · Q3 23.4% · Q4 16.0% · 4Q avg 13.4% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.2%
1.4 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.5% · Q3 0.0% · Q4 3.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.4% |
89.7%
24.3 pts worse
|
81.7%
16.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 65.4% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
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 2024-08-16
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-16
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-05
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-05
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 2023-07-28
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-29
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-29
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 2025-09-29
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-22
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 2024-08-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-22
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-22
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 2024-08-22
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-08-22
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-08-22
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-01
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 2023-06-01
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-01
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-01
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 2023-06-01
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-06-01
Health
Report COVID19 data to residents and families.
Corrected 2023-06-01
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-01
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-06-01
Penalties and ownership
Fine · fine $11,148
Fine
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Mortgage Interest · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
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