Cycle 1
Health 2025-09-04 · Fire 2025-09-04
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Temple, TX
Morada Temple
3-star overall rating with 3-star inspections with $14,722 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4312 S 31st St, Temple, TX
(254) 771-1226
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
60
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-07-17
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
0.56
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.50
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,246
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.70
Composite VBP score used to determine payment impact.
Payment multiplier
1.0049
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.76
Baseline 18.06% · Performance 18.76% · Measure score 5.76 · Achievement 5.76 · Improvement 0
Healthcare-associated infections
5.26
Baseline 7.32% · Performance 6.26% · Measure score 5.26 · Achievement 5.26 · Improvement 4.03
Total nurse turnover
2.10
Performance 55.10% · Measure score 2.10 · Achievement 2.10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
7.16
Baseline 5.03 hours · Performance 5.12 hours · Measure score 7.16 · Achievement 7.16 · Improvement 0.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 6.72% · Lower 95% interval 6.4% |
| Discharge to community | 68.83% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 102 · Observed rate 65.69% · Lower 95% interval 58.54% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.88% |
95.27%
1.6 pts better
|
Numerator 62 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 41.46% |
53.69%
12.2 pts worse
|
Numerator 17 · Denominator 41 |
| Discharge mobility score | 34.15% |
50.94%
16.8 pts worse
|
Numerator 14 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 64 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.26% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 3.45% · Lower 95% interval 3.2% |
| Staff COVID-19 vaccination coverage | 12.28% |
8.2%
4.1 pts better
|
Numerator 7 · Denominator 57 |
| Staff flu vaccination coverage | 42.86% |
42%
0.9 pts better
|
Numerator 24 · Denominator 56 |
| Discharge function score | 36.59% |
56.45%
19.9 pts worse
|
Numerator 15 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 92.5% |
96.28%
3.8 pts worse
|
Numerator 37 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 6.06% |
25.2%
19.1 pts worse
|
Numerator 2 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
97.1%
8.6 pts worse
|
93.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q3 75.0% · Q4 81.0% · 4Q avg 88.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
97.9%
2.9 pts worse
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.0% |
2.7%
8.3 pts worse
|
11.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.0% · 4Q avg 11.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.4% |
18.9%
15.5 pts worse
|
19.6%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.0% |
10.8%
8.2 pts worse
|
16.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
16.1%
7.4 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.5%
0.8 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.3% · 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 · 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 | 25.6% |
15.0%
10.6 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.2%
4.2 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
89.7%
3.2 pts worse
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 95.8% · Q3 86.2% · Q4 73.6% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
12.0%
4.7 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 6.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.5%
1.8 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.5% · Q3 3.2% · Q4 5.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.2% |
88.0%
4.8 pts worse
|
79.7%
3.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
25.9%
3.6 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 28.3% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-22 · Fire 2024-08-22
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-09-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-12
F · Potential for more than minimal harm
2024-08-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-08-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-08-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-08-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-06-29
K321 · Smoke Deficiencies
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 2023-11-30
E · Potential for more than minimal harm
2023-06-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-04
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 2025-09-25
D · Potential for more than minimal harm
2025-09-04
F657 · Resident Assessment and Care Planning Deficiencies
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 2025-09-25
D · Potential for more than minimal harm
2025-09-04
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 2025-09-25
D · Potential for more than minimal harm
2025-07-02
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 2025-07-03
E · Potential for more than minimal harm
2024-10-10
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-22
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 2024-09-12
E · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-12
J · Immediate jeopardy
2024-03-03
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 2024-03-04
J · Immediate jeopardy
2024-02-20
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 2024-02-22
J · Immediate jeopardy
2024-02-20
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 2024-03-12
J · Immediate jeopardy
2024-02-20
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-20
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 2024-02-22
E · Potential for more than minimal harm
2023-12-21
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 2024-01-20
D · Potential for more than minimal harm
2023-10-19
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 2023-10-28
F · Potential for more than minimal harm
2023-06-29
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 2023-07-31
E · Potential for more than minimal harm
2023-06-29
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 2023-07-31
D · Potential for more than minimal harm
2023-06-29
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 2023-07-31
D · Potential for more than minimal harm
2023-06-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-31
Penalties and ownership
What sits behind the stars
$14,722
2024-02-20
Fine
Fine · fine $14,722
Fine
Ownership
Hp Tenant Venture I LLC
5% Or Greater Direct Ownership Interest · Organization
Bullard, Hilary
Operational/Managerial Control · Individual
Erhardt, Jeffrey
Corporate Director · Individual
Morada Senior Living, LLC
Operational/Managerial Control · Organization
Quality Care Rehab Inc
Operational/Managerial Control · Organization
Robison, Tammy
Operational/Managerial Control · Individual
Wdtrs Tenant Holdings Iv, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Wojv Temple, LLC
5% Or Greater Mortgage Interest · Organization
Wojv-Dsh Venture Iv Member, LLC
5% Or Greater Indirect Ownership Interest · Organization
Wojv-Dsh Venture Iv, LLC
5% Or Greater Indirect Ownership Interest · Organization
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1-star overall rating with 1-star inspections with abuse icon flag with $7,257 in total fines with 4 recent health deficiencies
#3
Cornerstone Gardens Llp
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