Cycle 1
Health 2025-03-07 · Fire 2025-03-07
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lubbock, TX
Heritage Oaks Nursing and Rehabilitation Center
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5301 University Ave, Lubbock, TX
(806) 795-8792
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
159
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Slp Operations
Operator or chain grouping
Approved since
1994-06-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 2 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
0.25
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.03
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
0.13
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.90
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,607
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
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
3.16
Baseline 8.10% · Performance 6.96% · Measure score 3.16 · Achievement 2.92 · Improvement 3.16
Total nurse turnover
0.56
Performance 61.39% · Measure score 0.56 · Achievement 0.56 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.21
Baseline 3.73 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 11.76% · Lower 95% interval 6.85% |
| Discharge to community | 33.9% |
50.57%
16.7 pts worse
|
Worse than the National Rate · Eligible stays 41 · Observed rate 17.07% · Lower 95% interval 23.34% |
| Medicare spending per beneficiary | 1.5 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 83.33% |
95.27%
11.9 pts worse
|
Numerator 30 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 35% |
53.69%
18.7 pts worse
|
Numerator 7 · Denominator 20 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 5 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 91 |
| Staff flu vaccination coverage | 71.01% |
42%
29 pts better
|
Numerator 98 · Denominator 138 |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 8 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · 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 | 10% |
25.2%
15.2 pts worse
|
Numerator 2 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 2.0 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.8 · Expected 2.2 · 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 | 3.6% |
3.3%
0.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.8% · Q3 3.9% · Q4 6.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
2.7%
2.6 pts worse
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.9% · Q3 6.2% · Q4 7.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
3.3%
0.2 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.3% · Q3 2.4% · Q4 3.6% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
18.9%
2.2 pts worse
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 26.3% · Q3 18.9% · Q4 17.6% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
10.8%
8.5 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 2.7% · Q4 1.4% · 4Q avg 2.3% · 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 | 7.3% |
15.4%
8.1 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.8% · Q3 6.2% · Q4 13.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
16.1%
6.6 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 7.7% · Q3 12.5% · Q4 17.1% · 4Q avg 9.5% · 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 | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.5% |
15.0%
9.5 pts better
|
19.8%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 7.4% · Q3 7.5% · Q4 3.8% · 4Q avg 5.5% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
4.2%
7.1 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 12.3% · Q3 14.5% · Q4 9.9% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
89.7%
9.4 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.6% · Q3 98.7% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
12.0%
4.5 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 19.4% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.7% · Q3 2.6% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
25.9%
0.6 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 30.6% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-06
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 2026-02-20
D · Potential for more than minimal harm
2025-11-15
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-03-07
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-07
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 2025-04-14
D · Potential for more than minimal harm
2024-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-02-22
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 2024-03-30
E · Potential for more than minimal harm
2024-02-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-03-30
E · Potential for more than minimal harm
2024-02-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-30
E · Potential for more than minimal harm
2024-02-22
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 2024-03-30
E · Potential for more than minimal harm
2024-02-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-30
E · Potential for more than minimal harm
2024-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-02-22
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 2024-03-30
E · Potential for more than minimal harm
2023-11-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-03-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-01-05
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 2023-02-13
Penalties and ownership
What sits behind the stars
Ownership
Stratford Hospital District
5% Or Greater Direct Ownership Interest · Organization
Carlisle Taylor Whitworth 2020 Irrevocable Trust
5% Or Greater Mortgage Interest · Organization
Chumley, Richard
Corporate Director · Individual
Daniel, Timothy
Operational/Managerial Control · Individual
Gary Scott Whitworth 2019 Irrevocable Trust
5% Or Greater Mortgage Interest · Organization
Leonard, Joshua
Operational/Managerial Control · Individual
Lqcp Management, LLC
5% Or Greater Mortgage Interest · Organization
Mendez, Michael
Operational/Managerial Control · Individual
Slp Lubbock Heritage LLC
Operational/Managerial Control · Organization
Wm 41 Lubbock Heritage Re, LLC
5% Or Greater Mortgage Interest · Organization
Wm-Lqc Mm, LLC
5% Or Greater Mortgage Interest · Organization
Wt Holdings, LP
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Lakeside Rehabilitation And Care Center
Lubbock, TX
2-star overall rating with 3-star inspections with $8,994 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Lubbock Health Care Center
Lubbock, TX
3-star overall rating with 4-star inspections with 9 recent health deficiencies
#3
Hansford County Hospital District DBA Lakeridge Nu
Lubbock, TX
1-star overall rating with 2-star inspections with $30,561 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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