7Risk Axes

National percentile · lower = less risk · staffing gap is context only (not in composite)

How we calculate
SeverityElevated

99th national percentile — 31.0% high-severity citations

ChronicityModerate

49th national percentile — 6 repeat citations

Staffing integrityClean

None on file

Fire safetyWatch

4 citations

Weekend staffing dropLow

1th national percentile — 5.0%

Contract staff shareWatch

69th national percentile — 4.4%

Clinical trendElevated

70th national percentile — 2/5 measures worsened

Staffing gapAligned

Reported 3.96 vs expected 3.74 · +0.22 hr/res/day

Recent Health Violations

Health inspection citations from official Medicare records

29 citations on file
F-0656
G
Develop and implement a complete care plan that meets all the resident's…
Actual Harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey date: Sep 24, 2025 · Isolated — actual harm
F-0761
D
Ensure drugs and biologicals used in the facility are labeled in accorda…
Minimal Harm

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.

Survey date: Sep 24, 2025 · Isolated — no actual harm with potential for more
F-0686
G
Provide appropriate pressure ulcer care and prevent new ulcers from deve…
Actual Harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey date: Sep 24, 2025 · Isolated — actual harm
F-0689
D
Ensure that a nursing home area is free from accident hazards and provid…
Minimal Harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey date: Aug 14, 2024 · Isolated — no actual harm with potential for more

Recent Fire Safety Violations

Fire safety inspection citations from official Medicare records

4 citations on file
F-0712
F
Have simulated fire drills held at unexpected times
Potential Harm

Have simulated fire drills held at unexpected times.

Survey date: Sep 24, 2025 · Widespread — no actual harm with potential for more
F-0353
E
Inspect, test, and maintain automatic sprinkler systems
Potential Harm

Inspect, test, and maintain automatic sprinkler systems.

Survey date: Aug 14, 2024 · Pattern — no actual harm with potential for more
F-0321
E
Ensure that special areas are constructed so that walls can resist fire …
Potential Harm

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Survey date: Jul 13, 2023 · Pattern — no actual harm with potential for more
F-0353
E
Inspect, test, and maintain automatic sprinkler systems
Potential Harm↻ Repeat

Inspect, test, and maintain automatic sprinkler systems.

Survey date: Jul 13, 2023 · Pattern — no actual harm with potential for more

Better Nearby Options

Within 25 km · sorted by overall risk percentile

Full nearby list
Facility
CMS
Risk %ile
Tier
LEGACIES NURSING AND REHABILITATION
2.7 km · HEMPHILL, TX
★★★★★
CMS
33th
Risk %ile
Lower risk