Cycle 1
Health 2025-08-07 · Fire 2025-08-07
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Hereford, TX
Hereford Nursing & Rehabilitation
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
231 Kingwood St, Hereford, TX
(806) 364-7113
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-04-05
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
0.37
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.32
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
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,035
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9882
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.90
Performance 18.70% · Measure score 5.90 · Achievement 5.90 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0.99
Baseline 6.51% · Performance 7.54% · Measure score 0.99 · Achievement 0.99 · Improvement 0
Total nurse turnover
5.16
Baseline 42.31% · Performance 42.59% · Measure score 5.16 · Achievement 5.16 · Improvement 0
Adjusted total nurse staffing
1.64
Baseline 4.16 hours · Performance 3.55 hours · Measure score 1.64 · Achievement 1.64 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 6.63% |
| Discharge to community | 49.36% |
50.57%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 44.74% · Lower 95% interval 37.5% |
| Medicare spending per beneficiary | 1.49 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 35 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | 46.43% |
53.69%
7.3 pts worse
|
Numerator 13 · Denominator 28 |
| Discharge mobility score | 46.43% |
50.94%
4.5 pts worse
|
Numerator 13 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 35 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.54% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 66 |
| Staff flu vaccination coverage | 42.65% |
42%
0.6 pts better
|
Numerator 29 · Denominator 68 |
| Discharge function score | 35.71% |
56.45%
20.7 pts worse
|
Numerator 10 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 1.9 · 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 | 97.9% |
97.9%
About the same
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.3%
2.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 1.1% · 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 | 1.3% |
3.3%
2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.8% |
18.9%
10.9 pts worse
|
19.6%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 29.7% · Q3 27.8% · Q4 33.3% · 4Q avg 29.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 37.3% |
10.8%
26.5 pts worse
|
16.7%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 40.6% · Q3 35.5% · Q4 33.3% · 4Q avg 37.3% · 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 | 14.7% |
15.4%
0.7 pts better
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 23.2% · Q3 2.9% · Q4 8.8% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
16.1%
4.4 pts better
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 31.4% · Q3 0.0% · Q4 7.9% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.4% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
15.0%
1.3 pts better
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 18.2% · Q3 4.3% · Q4 10.9% · 4Q avg 13.7% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.2%
0.2 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 0.0% · Q3 0.0% · Q4 7.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 11.4% |
1.5%
9.9 pts worse
|
1.6%
9.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 11.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-18 · Fire 2024-07-18
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-09 · Fire 2023-06-09
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
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
2025-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-08-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-08-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-08-07
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-23
E · Potential for more than minimal harm
2024-07-18
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 2024-07-19
E · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-07-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-07-18
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 2024-07-19
D · Potential for more than minimal harm
2024-07-18
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 2024-07-19
E · Potential for more than minimal harm
2023-06-09
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 2023-06-10
E · Potential for more than minimal harm
2023-06-09
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 2023-06-12
D · Potential for more than minimal harm
2023-06-09
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 2023-06-10
Penalties and ownership
What sits behind the stars
Ownership
Terrel, Aaron
5% Or Greater Direct Ownership Interest · Individual
Terrel, Audra
5% Or Greater Direct Ownership Interest · Individual
Llano Estacado Healthcare LLC
Operational/Managerial Control · Organization
Terrel, Aaron
Operational/Managerial Control · Individual
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#3
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