Cycle 1
Health 2024-11-07 · Fire 2024-11-07
21 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Commerce, TX
Oak Manor Of Commerce Nursing And Rehabilitation
2-star overall rating with 2-star inspections with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2901 Sterling Hart Dr, Commerce, TX
(903) 886-2510
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Slp Operations
Operator or chain grouping
Approved since
1999-05-24
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
0.30
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.45
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.94
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.18
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,403
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
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
0
Performance 9.34% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.74
Performance 48.39% · Measure score 3.74 · Achievement 3.74 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.61 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.74% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 16% · Lower 95% interval 8.03% |
| Discharge to community | 36.64% |
50.57%
13.9 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 23.33% · Lower 95% interval 22.83% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 84% |
95.27%
11.3 pts worse
|
Numerator 21 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 12% |
2.29%
9.7 pts worse
|
Numerator 3 · Denominator 25 · Adjusted rate 9.47% |
| Healthcare-associated infections requiring hospitalization | 9.34% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 20% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 45 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 50 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · 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 | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.1
1.7 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.3 · Expected 1.4 · 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 | 6.7% |
3.3%
3.4 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.4% · Q3 6.5% · Q4 7.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
3.3%
2.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.9% |
18.9%
3 pts worse
|
19.6%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 22.2% · Q3 21.4% · Q4 27.5% · 4Q avg 21.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
10.8%
1.9 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.9% · Q3 9.4% · Q4 12.9% · 4Q avg 8.9% · 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 | 5.7% |
15.4%
9.7 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 9.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.1% |
16.1%
10 pts better
|
14.9%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.8% · Q3 4.9% · Q4 10.3% · 4Q avg 6.1% · 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 | 4.1% |
15.0%
10.9 pts better
|
19.8%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.4% · Q3 2.2% · Q4 7.7% · 4Q avg 4.1% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.2%
1.3 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.3% · Q3 2.5% · Q4 6.9% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
89.7%
1.7 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 91.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
1.5%
2.8 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-11 · Fire 2023-10-11
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-24 · Fire 2022-08-24
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-07
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 2024-12-05
E · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-11-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-05
C · Minimal harm
2024-11-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2023-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-10-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-22
C · Minimal harm
2023-10-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-22
F · Potential for more than minimal harm
2022-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-23
E · Potential for more than minimal harm
2022-08-24
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 2022-09-23
E · Potential for more than minimal harm
2022-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-23
C · Minimal harm
2022-08-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-08
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-08
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 2025-05-30
D · Potential for more than minimal harm
2025-05-08
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 2025-05-30
E · Potential for more than minimal harm
2024-11-07
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-11-07
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 2024-12-02
E · Potential for more than minimal harm
2024-11-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-11-07
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 2024-12-02
E · Potential for more than minimal harm
2024-11-07
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-11-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-11-07
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-07
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 2024-12-02
D · Potential for more than minimal harm
2024-11-07
F584 · Resident Rights Deficiencies
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 2024-12-02
D · Potential for more than minimal harm
2024-11-07
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 2024-12-02
D · Potential for more than minimal harm
2024-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-07
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-07
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 2024-12-02
D · Potential for more than minimal harm
2024-11-07
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 2024-12-02
D · Potential for more than minimal harm
2024-11-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-30
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 2024-11-19
D · Potential for more than minimal harm
2024-01-18
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 2024-02-15
D · Potential for more than minimal harm
2024-01-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-02-15
F · Potential for more than minimal harm
2023-10-11
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 2023-11-01
D · Potential for more than minimal harm
2023-10-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-10-11
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 2023-11-01
D · Potential for more than minimal harm
2023-10-11
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 2023-11-01
F · Potential for more than minimal harm
2022-08-24
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 2022-09-24
E · Potential for more than minimal harm
2022-08-24
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 2022-09-24
E · Potential for more than minimal harm
2022-08-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-09-24
D · Potential for more than minimal harm
2022-08-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-24
D · Potential for more than minimal harm
2022-08-24
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-09-24
D · Potential for more than minimal harm
2022-08-24
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 2022-09-24
D · Potential for more than minimal harm
2022-08-24
F808 · Nutrition and Dietary Deficiencies
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 2022-09-24
D · Potential for more than minimal harm
2022-08-24
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-09-24
Penalties and ownership
What sits behind the stars
Ownership
Nocona Hospital District
5% Or Greater Direct Ownership Interest · Organization
Leonard, Joshua
Operational/Managerial Control · Individual
Meekins, Greg
Corporate Officer · Individual
Slp Commerce LLC
Operational/Managerial Control · Organization
Wm 41 Coleman Re LLC
5% Or Greater Mortgage Interest · Organization
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#3
Briarcliff Health Center Of Greenville
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