Cycle 1
Health 2025-01-23 · Fire 2025-01-23
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Amarillo, TX
Hillside Heights Rehabilitation Suites
3-star overall rating with 3-star inspections with $14,901 in total fines with 12 recent health deficiencies
6650 South Soncy Road, Amarillo, TX
(806) 457-6700
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
120
Certified beds
Average residents
92
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
1995-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
69 facilities
Chain averages 2 overall / 2 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
0.46
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.71
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.10
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.28
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
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,594
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.29% · Performance 24.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.38% · Performance 7.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.28
Baseline 56.99% · Performance 58.43% · Measure score 1.28 · Achievement 1.28 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.77 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.75% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 231 · Observed rate 14.29% · Lower 95% interval 10.49% |
| Discharge to community | 55.48% |
50.57%
4.9 pts better
|
No Different than the National Rate · Eligible stays 198 · Observed rate 52.53% · Lower 95% interval 47.42% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.19% |
95.27%
3.9 pts better
|
Numerator 123 · Denominator 124 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 124 |
| Discharge self-care score | 21.93% |
53.69%
31.8 pts worse
|
Numerator 25 · Denominator 114 |
| Discharge mobility score | 24.56% |
50.94%
26.4 pts worse
|
Numerator 28 · Denominator 114 |
| Pressure ulcers or injuries, new or worsened | 2.42% |
2.29%
0.1 pts worse
|
Numerator 3 · Denominator 124 · Adjusted rate 2.6% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 148 · Observed rate 7.43% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 85 |
| Staff flu vaccination coverage | 80.46% |
42%
38.5 pts better
|
Numerator 70 · Denominator 87 |
| Discharge function score | 22.81% |
56.45%
33.6 pts worse
|
Numerator 26 · Denominator 114 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 98.21% |
96.28%
1.9 pts better
|
Numerator 55 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 3.13% |
25.2%
22.1 pts worse
|
Numerator 2 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.7% |
97.1%
26.4 pts worse
|
93.4%
22.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.3% · Q2 78.4% · Q3 83.5% · Q4 78.5% · 4Q avg 70.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.9%
0.9 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.8% |
2.7%
0.9 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.5% · Q3 0.0% · Q4 1.4% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
3.3%
0.7 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.3% · Q4 4.8% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
18.9%
2.6 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 15.8% · Q3 15.6% · Q4 12.7% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
10.8%
4.5 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 13.6% · Q3 19.6% · Q4 11.8% · 4Q avg 15.3% · 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 | 13.0% |
15.4%
2.4 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 9.2% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
16.1%
9.1 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.8% · Q3 4.9% · Q4 13.3% · 4Q avg 7.0% · 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 | 0.0% |
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 | 8.3% |
15.0%
6.7 pts better
|
19.8%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 9.9% · Q3 7.5% · Q4 2.5% · 4Q avg 8.3% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.2%
0.9 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.5% · Q3 6.2% · Q4 5.3% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 25.7% |
89.7%
64 pts worse
|
81.7%
56 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 39.2% · Q3 33.2% · Q4 18.6% · 4Q avg 25.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
12.0%
3.8 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 8.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.9% · Q3 0.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.1% |
88.0%
14.9 pts worse
|
79.7%
6.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
25.9%
6.2 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 18.3% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-13 · Fire 2022-10-13
11 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
J · Immediate jeopardy
2025-04-25
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 2025-04-07
D · Potential for more than minimal harm
2025-04-25
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-04
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 2025-03-24
E · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-22
E · Potential for more than minimal harm
2025-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-22
E · Potential for more than minimal harm
2025-01-23
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 2025-02-22
D · Potential for more than minimal harm
2025-01-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-02-22
D · Potential for more than minimal harm
2025-01-23
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 2025-02-22
D · Potential for more than minimal harm
2025-01-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-22
D · Potential for more than minimal harm
2025-01-23
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 2025-02-22
D · Potential for more than minimal harm
2025-01-23
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 2025-02-22
D · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-22
F · Potential for more than minimal harm
2023-12-06
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 2023-12-22
D · Potential for more than minimal harm
2023-12-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-06
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-06
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 2023-12-22
D · Potential for more than minimal harm
2023-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-10-31
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 2023-11-02
E · Potential for more than minimal harm
2023-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-06-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-04-27
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 2023-05-17
D · Potential for more than minimal harm
2023-04-27
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 2023-05-16
E · Potential for more than minimal harm
2022-10-13
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 2022-11-12
E · Potential for more than minimal harm
2022-10-13
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-11-12
E · Potential for more than minimal harm
2022-10-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-10-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-10-13
F849 · Administration Deficiencies
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 2022-11-12
Penalties and ownership
What sits behind the stars
$14,901
2025-04-25
Fine
Fine · fine $14,901
Fine
Ownership
Stratford Hospital District
5% Or Greater Direct Ownership Interest · Organization
Chumley, Richard
Corporate Director · Individual
Esquibel, Carol
Operational/Managerial Control · Individual
Thi Of Texas At Canyon, LLC
Operational/Managerial Control · Organization
Nearby options
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#3
Kirkland Court Health and Rehabilitation Center
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1-star overall rating with 1-star inspections with abuse icon flag with $25,480 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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