Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cherokee Rose Nursing And Rehabilitation during CMS and state inspections, most recent first.
Resident council meetings were not held in a private space because staff repeatedly walked through the dining room during the meetings. Residents said the interruptions prevented privacy and could allow their concerns to be overheard, while the AD and ADMN acknowledged staff sometimes crossed through the area despite posted signs and closed doors. The facility policy stated resident council would be provided private space and that staff could attend only by invitation.
A resident with COPD and HTN had orders for lisinopril and diltiazem with specific BP hold parameters, but MAR review showed both medications were given multiple times when recorded BP values were below the ordered limits. An MA stated she did not realize the resident had those specific parameters, and the DON stated staff were expected to follow physician orders and MAR parameters.
A dietary staff member pureed BBQ chicken, macaroni and cheese, and beans for a resident meal and left them at temperatures of 107 F, 106 F, and 119 F without reheating them before service. The DM also mechanically altered BBQ chicken for a mechanical soft diet without checking the temperature after alteration. Staff interviews confirmed the foods were served without being reheated to the required temperature.
Improper Storage of Nebulizers for Two Residents: Two residents receiving ordered nebulizer treatments had their nebulizers found not bagged and not dated when not in use. One resident had COPD and the other had acute respiratory failure; both were cognitively intact and on oxygen therapy. The DON stated nebulizers and oxygen tubing not in use should be placed in a plastic bag, and the facility policy required the nebulizer to be rinsed and stored in a labeled plastic bag.
Menu Not Followed for A Resident on Pureed Diet A resident with dysphagia, severe cognitive impairment, hospice services, and weight loss was on a pureed diet with health shakes. The posted lunch menu included a Honey Kissed Roll, and the tray ticket listed a pureed roll to be offered, but staff did not provide one. The cook stated she forgot to puree the roll, while other staff said the resident would choke on a roll and did not consider pureeing it, despite the expectation that all menu items be offered.
A resident with multiple medical conditions was provided with bed rails for mobility without a documented assessment for entrapment risk or informed consent from the resident or representative. Staff interviews confirmed that required assessments and consents were not completed prior to installation, contrary to facility policy.
The facility failed to ensure call lights were within reach for three residents, all with cognitive impairments and mobility issues. Observations revealed that call lights were either on the other side of the room or between the headboard and mattress, making them inaccessible. Staff interviews confirmed the expectation for call lights to be within reach, but unplanned construction and lack of a specific policy contributed to the oversight.
The facility failed to properly store and label medications on the C Hall medication cart and in the medication room. Loose pills were found in unlabeled cups, and the cart keys were left unattended in a binder on top of the cart. The DON and ADON were responsible for monitoring proper storage, but protocols were not followed, posing potential risks of medication errors and unauthorized access.
The facility did not follow the posted menu for a lunch meal, substituting items due to unavailable ingredients, which could affect residents' nutritional intake. The Dietary Manager noted missing substitution logs and a lack of inventory oversight, leading to deviations from the planned menu.
The facility failed to maintain food safety standards, including improper hand hygiene during meal prep, lack of labeling for open food items, and inadequate sanitization of thermometers. These actions could lead to foodborne illnesses and cross-contamination, as acknowledged by the Regional Certified Dietary Manager.
The facility failed to maintain effective infection control practices, as observed in two incidents. A CNA did not wear appropriate PPE while caring for a COVID-19 positive resident, and the resident was transported without a mask. Additionally, an LVN did not perform proper hand hygiene between obtaining a blood sample and administering insulin. These actions were contrary to the facility's infection control policies, highlighting deficiencies in PPE use and hand hygiene practices.
A facility failed to complete a Significant Change Assessment for a resident admitted to hospice care, despite the resident's severe cognitive impairment and serious health conditions. The MDS nurse responsible for the assessment was on sick leave, and miscommunication led to the oversight. The facility relied on the CMS's RAI Manual for guidance, lacking a specific policy for such assessments.
A facility failed to update a comprehensive care plan for a resident on hospice, despite a physician order. The resident, with severe cognitive impairment and multiple serious diagnoses, was admitted to hospice, but this was not reflected in the care plan. The MDS nurse responsible for updates was on sick leave, leading to miscommunication and the absence of a Significant Change Assessment. The DON acknowledged the oversight, which could have resulted in incorrect services for the resident.
A facility failed to document a hospice admission order in a resident's medical records, despite the resident having severe cognitive impairment and multiple serious health conditions. The order was only found in hospice records, not in the facility's electronic records or the resident's care plan. The DON stated the omission was due to a nurse forgetting to transcribe the order, contrary to facility policy.
Resident Council Meetings Lacked Privacy
Penalty
Summary
The facility failed to provide a private meeting space for resident council meetings, and staff continued to interrupt the meetings by walking through the dining room. During an observed confidential group meeting on 03/25/2026 between 1:30 p.m. and 1:50 p.m., a facility staff member opened the dining room door, walked through the dining room to the kitchen with a cup, then returned through the dining room and exited. Resident council members stated staff came in and out of the dining room during meetings and that the AD had placed signs at both entrances asking staff not to enter while resident council was being held, but staff did not respect the signs. The residents stated they felt their concerns may be overheard when staff cut through the dining room during the meetings. During interviews, the AD stated she closed the dining room doors and posted signs during resident council meetings to try to keep people from coming in, and she acknowledged that staff sometimes walked through the dining room to get items from the kitchen during the meetings. She stated she had asked staff to leave before when they were sitting at a table during resident council and did not feel the meetings were private. The ADMN stated staff were expected not to walk through the dining room during resident council meetings, that the door should remain shut, and that signs were posted to notify staff not to enter. He also stated staff had to walk through the dining room to get drinks for residents who did not attend the meetings if they wanted something other than water stored on the halls. The facility policy titled Resident Council stated the facility would provide the resident council with private space and that staff, visitors, or other guests may attend only at the group's invitation.
Failure to Follow Blood Pressure Medication Hold Parameters
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for one resident. Resident #13, a [AGE]-year-old female with COPD and hypertension, had physician orders for lisinopril 40 mg daily to be held if blood pressure was less than 140 systolic or 90 diastolic, and diltiazem 60 mg three times daily to be held if systolic was less than 140 or diastolic less than 90. Her quarterly MDS dated 03/03/2026 showed a BIMS score of 15, and her care plan identified hypertension with anti-hypertensive medications ordered. Review of the MAR showed lisinopril was administered six times in March 2026 when the recorded blood pressures were below the ordered hold parameters. The MAR also showed diltiazem was administered 22 times in March 2026 when the recorded blood pressures were below the ordered hold parameters. During interview, MA-D stated she did not realize the resident had those specific parameters and would have only noticed a systolic below 110 because that was the standard parameter. The DON stated staff were expected to follow physician orders and read the MAR for parameters, and the NP stated nurses were expected to follow the ordered parameters.
Food Not Reheated After Pureeing or Mechanical Alteration
Penalty
Summary
The facility failed to properly prepare and serve food in accordance with professional standards during lunch meal service for one kitchen reviewed. During observation, a staff member pureed BBQ chicken, baked macaroni and cheese, and homestyle beans for a resident’s meal, placing each item on a divided plate without taking temperatures at the time of preparation. The pureed foods were left by the blender and then moved to the steam table area, but no temperature checks were documented before service. When the temperatures were later taken, the pureed BBQ chicken measured 107 degrees F, the pureed baked macaroni and cheese measured 106 degrees F, and the pureed homestyle beans measured 119 degrees F. The staff member did not reheat any of the pureed food items after these temperatures were found. The food was then handed off for dining room delivery and served to the resident without being reheated prior to service. The observation also showed the dietary manager mechanically altered BBQ chicken to a mechanical soft texture and placed it into a pan on the steam table without taking the temperature after the texture change. The meal was later served to residents on a mechanical soft diet. Interviews with dietary and administrative staff confirmed that the food should have been reheated to the appropriate temperature after being found below holding temperature and after mechanical alteration, and that the temperature checks were not completed as expected.
Improper Storage of Nebulizers for Two Residents
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents who were receiving nebulizer treatments. Resident #13 had COPD, no cognitive impairment with a BIMS score of 15, and was on oxygen therapy. Her care plan directed staff to give aerosol or bronchodilator treatments as ordered, and physician orders included albuterol sulfate inhalation nebulization solution as needed for cough, congestion, or shortness of breath and budesonide inhalation suspension twice daily for COPD. During observation, Resident #13's nebulizer was found laying on the bedside table, not bagged, and with no date. The resident stated she had laid it there when her treatment was finished. Resident #20 had acute respiratory failure, no cognitive impairment with a BIMS score of 15, and was on oxygen therapy. Her care plan directed staff to give medications as ordered, and the physician order included ipratropium-albuterol inhalation solution every 4 hours as needed for shortness of breath. During observation, Resident #20's nebulizer was found lying in a drawer, not bagged, and not dated. She stated that the nurse had placed it there when her treatment was done. The DON stated that nebulizers and oxygen tubing not in use should have been placed in a plastic bag and that the nebulizer should have been placed in the bag after treatment; the facility policy also stated the nebulizer should be rinsed and stored in a labeled plastic bag.
Menu Not Followed for Pureed Diet Resident
Penalty
Summary
The facility failed to follow the posted menu for a resident on a pureed diet. Resident #19 was a female with dysphagia and cognitive communication deficit, had a BIMS score of 01 indicating severe cognitive impairment, and had a history of weight loss with hospice services and poor oral intake. Her care plan and dietitian notes reflected significant unplanned weight loss, a pureed diet, and health shakes three times daily. The record also stated there was no evidence she should not have pureed bread. On 03/24/2026, the posted lunch menu in the dining room listed BBQ Chicken Quarter, Baked Macaroni & Cheese, Homestyle beans, Honey Kissed Roll, and Apple Cobbler. During observation, the dietary staff member preparing the meal stated there was only one resident on a pureed diet and that no roll was pureed for Resident #19. At lunch, the resident was observed being fed pureed food, but there was no pureed roll on her tray. The ticket next to the tray listed a pureed honey kissed roll among the items to be offered, but the roll was not present. Interviews showed staff believed the resident could not have a roll because she was on a puree diet and would choke, while the dietary manager stated the expectation was that residents on a pureed diet be offered all menu items and believed the cook had pureed the roll. The cook stated she did not puree a roll and said she forgot to do so. The administrator stated the resident should have received all menu items unless bread was contraindicated, and the dietary manager and kitchen staff were responsible for ensuring the menu was followed.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for risk of entrapment from bed rails prior to their installation and did not review the risks and benefits of bed rails with the resident or the resident's representative, nor did it obtain informed consent before installation. Specifically, a cognitively intact female resident with a history of right femur fracture, hypertension, heart disease, and weakness was admitted and had physician orders for quarter bed rails to assist with mobility. The care plan included the use of side rails for safety and mobility, with instructions to observe for injury or entrapment and reposition as needed. However, there was no evidence in the resident's electronic medical chart of a completed bed rail assessment or signed consent for bed rail use. Observations confirmed the presence of bed rails on both sides of the resident's bed, and interviews with the resident and her representative revealed that the representative did not recall signing a consent form. Facility staff, including the ADON and ADMN, acknowledged that assessments and consents should have been completed and documented prior to bed rail installation, as required by facility policy. The failure to complete these steps was attributed to turnover in the DON position.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of three residents by not ensuring their call lights were within reach. Resident #8, a female with severe cognitive impairment and a history of falls, was observed lying in bed with her call light on the other side of the room's privacy curtain, out of her reach. Her care plan specifically required that her call light be within reach to mitigate her fall risk. Resident #21, who has moderate cognitive impairment and is dependent on staff for transfers, was found with her call light hanging between the headboard and mattress, not within arm's length. During an interview, she expressed a desire for more coke but was unable to call for assistance due to the inaccessible call light. Her care plan also emphasized the importance of having the call light within reach to prevent falls. Resident #37, with severe cognitive impairment and dependent on staff for transfers, was observed with her call light on the other side of the room's privacy curtain, similar to Resident #8. Interviews with staff, including CNAs and the DON, confirmed that the expectation was for all residents to have call lights within reach. The DON and ADMN acknowledged that the relocation of residents due to unplanned construction might have contributed to the oversight, but no specific policy was in place to ensure call lights were consistently accessible.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional principles, specifically on the C Hall medication cart and in the medication room. During an observation, it was found that the C Hall medication cart contained 15 loose pills in unlabeled medication cups, which were stored improperly after residents refused them. The medication aide, MA D, admitted to storing these medications incorrectly and acknowledged her responsibility for proper storage. Additionally, the keys to the medication cart were left unattended in a binder labeled 'Narcotic Book C Hall' on top of the cart, which was against the facility's policy. Further observations revealed that the C Hall medication cart was left unattended outside the nurses' station, with the keys still in the binder. LVN E, who was present, stated that the keys should be kept on the person responsible for the cart and not left unattended. The cart contained various medications, including heart medications, psychotropic drugs, nasal spray, and narcotics. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were responsible for monitoring the proper storage of medications, but the failure to adhere to these protocols was evident. Interviews with the DON, ADON, and the consultant pharmacist (CP) highlighted the expectation that medications should be discarded if refused by residents and that keys should remain with the responsible staff member. The facility's policies on medication storage and labeling were not followed, leading to potential risks of medication errors and unauthorized access. The report did not indicate any specific negative outcomes for residents but emphasized the importance of adhering to proper storage and labeling practices to prevent such risks.
Failure to Follow Menu and Ensure Nutritional Needs
Penalty
Summary
The facility failed to ensure that the menus met the nutritional needs of residents and were followed as per the established guidelines. On the observed date, the lunch meal did not include the items listed on the posted menu, which were recommended by the licensed dietician. Instead of the planned grilled steak with onions, baked potatoes, and sauteed broccoli, the facility served Salisbury steak, garlic parmesan mashed potatoes, and mixed vegetables. Additionally, cheesecake with fruit topping was substituted with green Jell-O with fruit. The staff member responsible for preparing the meal admitted to not following recipes and substituting items due to the unavailability of the listed ingredients. The Regional Certified Dietary Manager expressed concerns that the substitutions could alter the overall calorie intake and negatively impact the residents' diets. It was revealed that prior to the new Dietary Manager's appointment, inventory was not completed, leading to a lack of necessary ingredients. The Dietary Manager confirmed that the substitution logs were blank, and previous logs were missing, indicating a lack of oversight and supervision in ensuring that the dietary staff followed the menu. The facility's policy required that any meal variation from the planned menu be recorded on the substitution log, which was not adhered to in this instance.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Staff did not practice appropriate hand hygiene during meal preparation, which included failing to wash hands after handling various items and before engaging in food preparation tasks. This was observed when staff members handled food items, such as Jell-O containers and hamburger patties, without washing their hands before or after glove use, and after touching potentially contaminated surfaces like trash cans. Additionally, the facility did not label open food items with the date they were opened or their expiration dates. This was noted with several food items, including bags of cabbage, pudding containers, and pita bread, which were stored in the refrigerator without proper labeling. The Dietary Manager admitted to not knowing how long some items had been stored, which could lead to the use of spoiled food. The facility also failed to ensure that thermometers used for checking food temperatures were properly sanitized between uses. A staff member was observed using a thermometer on different food items without cleaning it in between, which could lead to cross-contamination. The Regional Certified Dietary Manager acknowledged that these practices did not meet the facility's expectations and could negatively impact residents by spreading germs and causing foodborne illnesses.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a Certified Nursing Assistant (CNA) who did not wear appropriate personal protective equipment (PPE) while providing care to a resident with an active COVID-19 infection. The CNA was observed exiting the resident's room wearing only a surgical mask and gown, without gloves or a face shield, and transported the resident to the shower room without the resident wearing a mask. The CNA admitted to not being informed about the resident's COVID-19 status and acknowledged that the resident should have been masked during transportation. Another deficiency was noted with a Licensed Vocational Nurse (LVN) who failed to perform proper hand hygiene while obtaining a blood sample for glucose testing. The LVN did not change gloves or sanitize hands between handling the glucometer and administering insulin to the same resident. This practice was contrary to the facility's infection control policies, which emphasize the importance of hand hygiene to prevent cross-contamination and infection spread. The Director of Nursing (DON) confirmed that the LVN's actions were not in line with expected procedures and acknowledged that staff had been trained on infection control. The facility's policies on infection control and COVID-19 precautions were not adequately followed, as evidenced by the lack of appropriate PPE use and hand hygiene practices. The DON and medical director provided insights into the expected standards of care, including the use of masks, gowns, gloves, and face shields when caring for COVID-19 positive residents. However, the observed practices did not align with these expectations, indicating a gap in the implementation of the facility's infection control program.
Failure to Complete Significant Change Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Assessment for a resident who was admitted to hospice care. The resident, a male with severe cognitive impairment and multiple serious health conditions, including a traumatic brain injury, sepsis, respiratory failure, and Type 2 diabetes, was admitted to the facility and later to hospice. Despite the hospice admission, there was no evidence of a Significant Change Assessment being completed, which is required to accurately reflect the resident's current medical condition and ensure appropriate care. Interviews with facility staff revealed that the Director of Nursing (DON) expected the assessment to be completed within 14 days of the hospice admission. The MDS nurse, who was responsible for completing the assessment, was on sick leave, and the responsibility fell to the RRN. The RRN acknowledged that the hospice admission should have triggered the assessment, but miscommunication led to the failure. The nurse who received the hospice order did not enter it into the system, which would have prompted the assessment process. The facility did not have a specific policy for Significant Change Assessments, relying instead on the CMS's RAI Manual.
Failure to Update Care Plan for Hospice Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was on hospice, which was not reflected in the care plan. The resident, a male with severe cognitive impairment, was admitted with multiple serious diagnoses including traumatic subdural hemorrhage, sepsis, respiratory failure, and Type 2 diabetes. Despite a physician order to admit the resident to hospice, the care plan was not updated to reflect this significant change. The Director of Nursing (DON) acknowledged that the care plan should have been updated following a Significant Change Assessment, which was not completed. The failure to update the care plan was attributed to miscommunication and the absence of a Significant Change Assessment. The MDS nurse, who was responsible for updating the care plan, was on sick leave, and the responsibility fell to the RRN, who did not complete the necessary updates. The facility lacked a specific policy for Significant Change Assessments, relying instead on the CMS's RAI Manual. The oversight could have resulted in the resident receiving incorrect services, as the care plan did not reflect the resident's hospice status.
Failure to Document Hospice Admission in Resident's Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of hospice care. The resident, a male with severe cognitive impairment and multiple serious health conditions, was admitted to the facility with a diagnosis of traumatic subdural hemorrhage, sepsis, respiratory failure, and Type 2 diabetes. Despite a physician order to admit the resident to hospice on a specific date, this order was not entered into the facility's electronic medical records, nor was it reflected in the resident's comprehensive care plan. During an interview, the Director of Nursing (DON) acknowledged that the nurse responsible for receiving physician orders should have entered the order into the electronic medical records system. The DON admitted that the failure to update the comprehensive care plan with hospice information was due to the charge nurse forgetting to transcribe the record. The facility's policy requires nurses to review and enter physician orders into the electronic charting system, which was not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Glen Rose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glen Rose Nursing And Rehab Center | 0.5 mi | ★★★★★ | 10 | 0 |
| Granbury Rehab & Nursing | 13.6 mi | ★★★★★ | 20 | 0 |
| Harbor Lakes Nursing And Rehabilitation Center | 13.9 mi | ★★★★★ | 8 | 0 |
| Granbury Care Center | 14.6 mi | ★★★★★ | 13 | 1 |
| Trinity Nursing & Rehab Of Granbury | 15.2 mi | ★★★★★ | 3 | 0 |
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