Cycle 1
Health 2025-07-23 · Fire 2025-07-23
5 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Waco, TX
The Highlands Nursing and Rehabilitation
2-star overall rating with 2-star inspections with $241,937 in total fines with 5 recent health deficiencies
2501 Maple Ave, Waco, TX
(254) 752-0311
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
162
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gulf Coast Ltc Partners
Operator or chain grouping
Approved since
1983-05-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 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
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.74
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.91
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.58
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,349
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 68.75% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.26
Baseline 3.79 hours · Performance 3.44 hours · Measure score 1.26 · Achievement 1.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 7.5% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 81 |
| Staff flu vaccination coverage | 86.6% |
42%
44.6 pts better
|
Numerator 84 · Denominator 97 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| 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 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · 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 | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.8 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.5 |
2.1
2.4 pts worse
|
1.8
2.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 5.5 · Expected 2.1 · 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 | 1.4% |
3.3%
1.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 1.4% · 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 | 3.8% |
3.3%
0.5 pts worse
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 6.5% · Q3 4.2% · Q4 2.0% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
18.9%
7.2 pts better
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 8.5% · Q3 7.8% · Q4 12.7% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
10.8%
8.4 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.8% · Q3 13.3% · Q4 17.2% · 4Q avg 19.2% · 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 | 10.0% |
15.4%
5.4 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.9% · Q3 13.3% · Q4 5.0% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
16.1%
6.1 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 11.4% · Q3 9.5% · Q4 13.0% · 4Q avg 10.0% · 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 | 10.2% |
15.0%
4.8 pts better
|
19.8%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 10.4% · Q3 16.9% · Q4 7.1% · 4Q avg 10.2% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.2%
2.1 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 8.9% · Q3 6.9% · Q4 4.1% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
89.7%
4.2 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 92.3% · 4Q avg 93.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
88.0%
0.9 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
5 health deficiencies
Top issue: Environmental (1 deficiency)
25 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2024-06-13
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-06-12
F · Potential for more than minimal harm
2024-06-13
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-05-14
F · Potential for more than minimal harm
2024-06-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-05
F · Potential for more than minimal harm
2024-06-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-14
F · Potential for more than minimal harm
2024-06-13
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 2025-05-31
F · Potential for more than minimal harm
2024-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-06-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-06-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-06-13
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 2025-05-31
F · Potential for more than minimal harm
2024-06-13
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-06-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-06-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-31
E · Potential for more than minimal harm
2024-06-13
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-05-31
E · Potential for more than minimal harm
2024-06-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-31
E · Potential for more than minimal harm
2024-06-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-31
E · Potential for more than minimal harm
2024-06-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-05-31
E · Potential for more than minimal harm
2024-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-31
E · Potential for more than minimal harm
2024-06-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-31
D · Potential for more than minimal harm
2024-06-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-31
D · Potential for more than minimal harm
2024-06-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-31
D · Potential for more than minimal harm
2024-06-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-31
D · Potential for more than minimal harm
2024-06-13
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-05-31
C · Minimal harm
2024-06-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-17
C · Minimal harm
2023-05-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Not marked corrected
C · Minimal harm
2023-05-10
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
E · Potential for more than minimal harm
2025-07-23
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 2025-08-15
E · Potential for more than minimal harm
2025-07-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-23
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-23
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 2025-08-15
D · Potential for more than minimal harm
2025-07-23
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-08-15
E · Potential for more than minimal harm
2024-06-13
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-13
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 2024-07-03
E · Potential for more than minimal harm
2024-06-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-13
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-07-05
J · Immediate jeopardy
2023-12-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-17
J · Immediate jeopardy
2023-12-29
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 2024-01-17
J · Immediate jeopardy
2023-12-29
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 2024-01-17
D · Potential for more than minimal harm
2023-05-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-06-09
J · Immediate jeopardy
2023-04-29
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 2023-06-01
J · Immediate jeopardy
2023-04-29
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 2023-06-01
D · Potential for more than minimal harm
2023-03-10
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 2023-04-28
D · Potential for more than minimal harm
2023-03-10
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 2023-04-28
D · Potential for more than minimal harm
2023-03-10
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2023-03-11
Penalties and ownership
What sits behind the stars
$138,753
2025-04-16
Fine
Fine · fine $138,753
Fine
$8,954
2023-12-29
Fine
Fine · fine $8,954
Fine
$94,230
2023-04-29
Fine
Fine · fine $94,230
Fine
$0
2023-04-29
Payment Denial
Payment Denial · denial start 2023-06-03 · 6 days
6 day denial
Ownership
Coryell County Memorial Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Beasley, Carolyn
Operational/Managerial Control · Individual
Byrom, David
Corporate Director · Individual
Jian, Peter
Operational/Managerial Control · Individual
Mistretta, Cassandra
Operational/Managerial Control · Individual
Pfeifer, Mary
Operational/Managerial Control · Individual
Waco Opco LLC
Operational/Managerial Control · Organization
Nearby options
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1-star overall rating with 1-star inspections with abuse icon flag with $79,787 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
The Atrium Of Bellmead
Bellmead, TX
4-star overall rating with 5-star inspections with 4 recent health deficiencies
#3
Avir at Jeffrey Place
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2-star overall rating with 2-star inspections with $29,666 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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