Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Hereford Nursing & Rehabilitation during CMS and state inspections, most recent first.
Invalid DNR Documentation for a Resident with Severe Cognitive Impairment: A resident with Alzheimer's disease, severe cognitive impairment, hospice services, and continuous O2 had a DNR on file that was signed by the resident and witnesses but was not signed and dated by a physician, and the notary's signature and seal were not dated. The LVN, DON, and Administrator all acknowledged the DNR was not valid, and staff said they would need clarification or would send the resident to the ER if cardiac arrest occurred.
A facility failed to follow its abuse/neglect policy when it did not report an unexplained black eye on a cognitively impaired resident and did not report a missing diamond ring belonging to another cognitively impaired resident. Staff documented the bruise and discussed the injury, but leadership stated they did not know it had to be reported to the state. For the missing ring, staff and family knew the item was gone, a grievance was written, and the ADM searched for it, but no state report was made.
Failure to Report Injury of Unknown Source and Missing Resident Property: The facility did not report a resident’s unexplained black eye and another resident’s missing diamond ring to state authorities. Both residents had cognitive impairment and dementia. The injury was documented after the resident was noted with a bruise under the eye while showering, and the missing ring was discussed with the family and facility leadership, but no state report was made as required by policy.
Failure to Thoroughly Investigate Injury of Unknown Source and Missing Resident Property: The facility did not thoroughly investigate a resident’s unexplained black eye after self-showering, with staff giving differing accounts and incomplete documentation, and it also did not thoroughly investigate another resident’s missing diamond ring. The second resident had dementia and cognitive impairment, reported the ring stolen, and family said the ring disappeared from a ring keeper while staff and the ADM searched and contacted a pawn shop without documenting key investigative steps.
A facility failed to complete significant change MDS assessments within the required timeframe for two residents after hospice enrollment. Both residents had severe cognitive impairment and hospice-related records in the EHR, but the MDS completion dates were beyond the 14-day window after the hospice election/effective dates. The MDS LVN believed the work was timely because it was finished within 14 days, while the DON signed the assessments as complete later and did not know why the timeframe was missed.
A CNA contaminated clean gloves during incontinence care for a resident who was cognitively intact and frequently incontinent of bowel and bladder, then continued care using gloves from the contaminated bag. In a separate observation, an LPN used the same BP cuff on two residents without disinfecting it between uses. The ADM and DON stated staff were trained to keep clean supplies separated and to disinfect resident-care equipment after each use, and the DON was not aware of the observed lapses.
The facility failed to properly store, label, and date food items in the kitchen, as observed in the pantry and freezer. Open and unlabeled graham cracker pie crusts and imitation vanilla were found in the pantry, while hamburger patties in the freezer were open to air with freezer burn. Interviews with staff revealed that all employees were responsible for labeling and disposing of expired foods, but these practices were not followed, posing potential health risks to residents.
The facility failed to maintain an effective infection prevention and control program, as staff members did not wear PPE gowns during high-contact care activities for two residents. This included administering medications and performing catheter, incontinent, and wound care. Staff interviews revealed a lack of awareness and training on Enhanced Barrier Precautions (EBP), contributing to the deficiency.
A resident with severe cognitive impairment and multiple health issues was found with her call light out of reach, contrary to her care plan and facility protocol. Staff interviews confirmed the oversight, acknowledging the importance of call light accessibility to prevent negative outcomes such as falls.
A facility failed to conduct a safety assessment and obtain informed consent before installing a bed rail for a resident with severe cognitive impairment and limited mobility. The resident was observed with a one-third bed rail without proper documentation, and staff interviews revealed a lack of awareness regarding the bed rail's size and necessary procedures. This oversight could risk resident safety and hinder daily activities.
The facility failed to store and label medications properly, with expired medication found in the medication room and loose pills in a medication cart. An LVN was unsure why expired medication was present, and the DON acknowledged the risk of missed doses. Facility policies on medication storage and labeling were not followed.
Invalid DNR Documentation for a Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that Resident #19 had a valid Do Not Resuscitate (DNR) order in place that was signed by a physician and dated by the notary public. Resident #19 was admitted with diagnoses including Alzheimer's disease, type 2 diabetes mellitus with diabetic polyneuropathy and hypoglycemia, adult failure to thrive, anxiety disorder, COVID-19, insomnia, and major depressive disorder. Her quarterly MDS showed she required partial to moderate assistance with self-care and mobility, had an indwelling catheter, was occasionally incontinent of bowel, received continuous oxygen at 2-5 liters per minute, and was on hospice services twice per week. Her BIMS score was 04, indicating severe cognitive impairment. Review of the care plan showed an order for DNR with interventions stating CPR would not be initiated and comfort measures would be maintained as ordered by the physician. The resident's DNR document was signed by the resident, signed by two witnesses, and notarized, but the notary's signature and seal were not dated, and the form was not signed and dated by a physician. The resident's active physician orders included comfort medications such as fentanyl transdermal patch and morphine sulfate oral solution. During interviews, an LVN stated the DNR was not valid because it was not signed by a physician and said she would have to ask the DON for clarification if the resident went into cardiac arrest. The DON also stated the DNR was not valid because it lacked the physician signature and date and the notary had not dated the signature and seal, and said the facility would have to send the resident to the ER via ambulance if cardiac arrest occurred. The Administrator stated the resident's code status book would be used to determine code status, but also acknowledged the current sheet would be invalid because it lacked the required physician signature and notary date.
Failure to Report Injury of Unknown Source and Missing Resident Property
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property for 2 residents reviewed. The facility’s Abuse/Neglect policy stated that all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source were to be reported and investigated, with notification to the state required by the administrator or designee. However, the events involving Resident #8 and Resident #30 were not reported to state authorities as required by the facility’s policy. Resident #8 was a cognitively impaired male with dementia and a BIMS score of 8. He was receiving aspirin and clopidogrel and required supervision or assistance with ADLs. Progress notes and an incident report documented a bruise under his right eye after he was in the shower. The incident report described the injury as a bruise to the right eye with no witness, and staff initially documented that the resident had been showering and later noticed with a bruise. During the survey, Resident #8 had fading bruising under his right eye and gave inconsistent explanations about how it occurred. Staff interviews showed that the LVN and DON discussed the injury, but the DON stated she did not know it was necessary to report the black eye to the state, and the ADM stated he did not know he was supposed to report it. Resident #30 was a cognitively impaired female with dementia and a BIMS score of 10. Her family member reported that her diamond solitaire ring disappeared while it was on her finger in a ring keeper with other rings. The resident stated her diamond ring had been stolen, and the family member described the ring as missing after a visit when it had previously been present. The facility documented a grievance about the missing ring, and staff searched for it and contacted a pawn shop, but there was no incident report or state report for misappropriation of resident property. Interviews showed that staff and leadership knew the ring was missing and discussed it, but the DON stated the grievance was why it was not reported to the state, and the ADM stated he did not know he was supposed to report the missing ring to the state.
Failure to Report Injury of Unknown Source and Missing Resident Property
Penalty
Summary
The facility failed to ensure that allegations involving abuse, neglect, exploitation, mistreatment, and misappropriation of resident property were reported to the proper authorities within the required timeframe for two residents. One resident had a black eye that was documented after he was noted with a bruise under his right eye while showering. The incident report described the injury as a bruise to the face, noted that the resident had been self-showering, and listed the physician, DON/RN, and family member as notified, but there was no report to state authorities. The resident had diagnoses including dementia and cognitive communication deficit, with a BIMS score of 8 indicating moderate cognitive impairment. The second resident, who also had dementia and cognitive communication deficit with a BIMS score of 10, was involved in a missing property allegation when her diamond solitaire ring was reported missing. The resident stated the ring had been stolen, and her family member reported that the ring had been on her finger with other rings held together by a ring keeper before it disappeared. The family member stated he informed the MDS LVN, who notified the DON and ADM, and the ADM contacted a local pawn shop. The facility documented a grievance regarding the missing ring, but there was no incident report or state report for misappropriation of resident property. During interviews, the DON stated she did not think there was a negative outcome if an injury of unknown origin was not reported to the state and did not know of a possible negative outcome of not reporting missing resident property to the state. The ADM stated he did not know he was supposed to report the resident’s black eye and missing ring to the state, and he indicated he was responsible for reporting incidents to the state. The facility policy stated that allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injury of unknown source must be reported to the administrator, and the administrator or designee must report the allegation to HHSC within the required timeframe.
Failure to Thoroughly Investigate Injury of Unknown Source and Missing Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source for Resident #8, who had dementia, cognitive communication deficit, and a BIMS score of 8 indicating moderate cognitive impairment. He was receiving aspirin and clopidogrel. The record showed a bruise incident involving a bruise under his right eye after he had been self-showering in the shower area. The incident report noted that the resident denied falling and that the showerhead was a removable sprayer that comes off the wall. A progress note later stated that the dialysis center called about a black eye and that it was explained as being caused by a shower head that fell onto his eye, but no other progress notes were found about the injury. During interview, the LVN who completed the incident report stated she did not see the shower head fall on the resident’s eye and that when she first interviewed him, he said he did not know how it happened. She later said he told her the shower head fell on his eye, but she forgot to document that conversation anywhere. The DON stated staff should report injuries of unknown origin and that the facility investigates them, but she also stated she was not sure which aide was with the resident in the shower. The ADM stated the resident was fine when he went into the shower and had a black eye when he came out, and he believed the resident probably bumped his head on the shower head. The report states that the facility did not complete a thorough investigation of the injury. The facility also failed to complete a thorough investigation of misappropriation of Resident #30’s property involving a missing diamond ring. Resident #30 had dementia, cognitive communication deficit, and a BIMS score of 10 indicating moderately impaired cognition. Her progress notes did not mention the missing ring, although one note documented that she was slapping and hitting staff and other residents and making accusations that staff and other residents were stealing her things. A grievance was written regarding the missing ring, and the resident told the surveyor that a diamond ring had been stolen. Her family member stated the ring had been on her finger with other rings inside a ring keeper and that the diamond solitaire ring disappeared while the other rings remained in place. The family member stated he reported the missing ring to the MDS LVN, who notified the DON and ADM, and that the ADM called the owner of a local pawn shop. The MDS LVN stated she and the ADM searched the resident’s room for the ring. The ADM stated he spoke to staff who worked on the days the ring disappeared, but he did not document those conversations or his search for the ring. He also stated he called the pawn shop owner and asked to be notified if the ring came in, but he did not document that call. The DON stated the ADM investigated and that he wrote a grievance regarding the ring. The report states that the facility did not complete a thorough investigation of the missing property.
Delayed Significant Change MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to complete significant change MDS assessments within 14 days after determining that two residents had a significant change in condition related to hospice enrollment. Resident #4 was admitted to the facility with a diagnosis that included Alzheimer's disease, and hospice paperwork in the EHR showed a hospice certification signed by the physician with an election and effective date of 07/16/25. Her significant change MDS was completed on 08/05/25, and the RN signature at Z0500 was the DON's signature. Resident #39 was admitted with diagnoses including Alzheimer's disease, anxiety disorder, and Parkinsonism. Her record showed hospice as the primary payer and listed a hospice provider, and hospice paperwork in the EHR showed an election and effective date of 12/26/24 with a physician voice order for hospice care on that date. Her significant change MDS was completed on 01/20/25, and the RN signature at Z0500 was the DON's signature. During interviews, the LVN responsible for MDS assessments stated she was responsible for completing them timely and believed the assessments for Resident #4 and Resident #39 were completed timely because the work was done within the 14 days allowed, regardless of when the DON signed them as complete. The DON stated she signed the assessments as complete because she was an RN, but did not know why the two significant change assessments were not signed within the 14-day timeframe. The ADM stated the MDS LVN was responsible for ensuring assessments were completed timely.
Infection Control Lapses During Incontinence Care and Equipment Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 of 15 residents reviewed for infection control. During incontinence care for Resident #37, a CNA placed clean wipes and clean gloves on a table in the resident’s room, then reached into the clean bag with contaminated gloves to grab the wipes. While doing so, the CNA picked up the clean gloves with contaminated gloves and placed them back into the bag. The CNA then changed gloves, washed her hands with soap and water, and donned contaminated gloves from the bag to finish the incontinence care. Resident #37’s record showed a history of type two diabetes, muscle weakness, and chronic kidney disease, and the annual MDS indicated the resident was cognitively intact and frequently incontinent of bowel and bladder. During a medication administration observation, an LVN used the same blood pressure cuff on Resident #35 and then on Resident #40 without disinfecting the equipment between uses. No sanitation of the blood pressure cuff was observed before or after it was used on either resident. During interview, the LVN stated she had been trained to disinfect the blood pressure cuff between residents, but said she did not disinfect it because she had a bad habit of not doing so. Interviews with the ADM and DON confirmed that staff were trained on infection control and that staff were expected to keep clean gloves and wipes separated during incontinence care and to disinfect the blood pressure cuff after each resident use. The DON stated she was not aware staff had contaminated clean gloves during incontinence care or had not disinfected the blood pressure cuff after use on residents. Facility policy stated that if contamination occurs during the skill, staff should start over from the beginning, and that resident-care equipment used on another resident should be adequately cleaned and disinfected before use.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage, labeling, and dating of food items in the kitchen. During an observation of the walk-in pantry, it was noted that there were four graham cracker pie crusts in a package that were not sealed and open to air, with no date or label. Additionally, an open gallon of Big Chief Imitation Vanilla Flavor was found with an expiration date but no open date. In the freezer, a box of hamburger patties was observed to be open to air with no open date, and a small amount of freezer burn was noted on the top patties. Interviews with the Dietary Coordinator (DC) and Dietary Supervisor (DS) revealed that all employees were responsible for disposing of expired foods and ensuring that foods were labeled and sealed. The DC acknowledged that failing to dispose of expired items could result in residents getting sick. The DS confirmed that not sealing or labeling foods properly could lead to freezer burn and potential health risks for residents. The facility's policies on labeling, dating, and storing food were reviewed, indicating that opened food items must be dated and stored in closed containers, but these policies were not followed, leading to the observed deficiencies.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of four staff members and the care of two residents. LVN E did not wear a PPE gown while administering medications via PEG-tube to a resident and during Foley catheter care, incontinent care, and wound care for another resident with a Stage 3 pressure ulcer. Similarly, CNA G and CNA H assisted in these procedures without donning PPE gowns. LVN D also failed to wear a PPE gown while administering liquid feeding via PEG-tube to a resident. These practices were observed without the presence of PPE gowns in the residents' rooms or nearby hallways. The residents involved included a 48-year-old female with cerebral palsy, requiring total assistance with ADLs, and a 61-year-old male with a Stage 3 pressure ulcer and obstructive uropathy, requiring an indwelling Foley catheter. The care plans for these residents indicated the need for enhanced barrier precautions, which were not followed by the staff. Interviews with the staff, including LVNs and CNAs, revealed a lack of awareness and training regarding Enhanced Barrier Precautions (EBP) and the importance of PPE gown usage during high-contact care activities. The facility's policies and procedures, including those for infection control, catheter care, and medication administration, were not adhered to by the staff. The Director of Nursing (DON) and other staff members were unaware of the EBP policy, and there was no evidence of recent in-service training on this topic. The administrator acknowledged the existence of the EBP policy but noted that the current DON, who started in April 2024, might not have been informed about it. This lack of training and awareness among staff members contributed to the deficiency in infection control practices.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident #4 had reasonable accommodation for her needs and preferences, specifically regarding the accessibility of her call light. Resident #4, a female with severe cognitive impairment and multiple diagnoses including parkinsonism, dementia, and a history of falling, was observed sitting in her recliner with her call light out of reach. The call light, which was supposed to be within easy reach as per her care plan, was found on the floor and on her bed, both inaccessible to her. This oversight was noted during an observation and interview, where Resident #4 expressed a need to use the bathroom but was unable to reach the call light to request assistance. Interviews with facility staff, including a CNA, LVN, ADON, and DON, confirmed that it was protocol for call lights to be within reach of residents to prevent potential negative outcomes such as falls. The staff acknowledged the failure to adhere to this protocol, which was also outlined in the facility's policy on call light use. The policy emphasized the importance of ensuring call lights are accessible to residents and that staff should be aware of their placement at all times. Despite this policy, the call light was not positioned conveniently for Resident #4, leading to the deficiency noted by the surveyors.
Failure to Follow Bed Rail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow proper procedures before installing a bed rail for Resident #13, who was observed with a one-third bed rail on the right side of her bed without documentation of consent or a safety assessment. Resident #13, a female with severe cognitive impairment and limited physical mobility, required a two-person assist for transfers. Despite the physician's standing orders indicating that side rails should be used when necessary, there was no documentation of a bed rail safety assessment for the one-third size bed rails, nor was there a signed consent for their use. Interviews with facility staff revealed a lack of awareness regarding the size of the bed rails on Resident #13's bed and the necessary procedures for their use. LVN A acknowledged the requirement for assessments and consents but was unaware of the bed rail's removal, which was directed by the ADON following a family request. The facility's policy mandates an assessment and consent prior to bed rail installation, which was not adhered to in this case, potentially placing residents at risk of injury or hindering their ability to engage in daily activities.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to currently accepted professional principles. During an observation and interview, it was found that a medication for a resident had expired in June 2023 but was still present in the medication room. The Licensed Vocational Nurse (LVN) was unsure why the expired medication was still there and could not specify any negative outcomes from having expired medication in the room. Additionally, loose pills were discovered in the bottom of the medication cart drawers on Hall 200, and the Medication Aide (MA) was unable to identify these medications. The Director of Nursing (DON) was asked about the potential negative outcomes of having loose medications in the cart and mentioned the possibility of a missed dose. The facility's policies, which were reviewed, stated that drugs should be stored in their original packaging and that discontinued or outdated drugs should not be used. These policies also outlined that medications should be properly labeled and that expired or discontinued medications should be submitted to the DON for destruction. Despite these policies, the facility did not adhere to them, leading to the deficiencies observed.
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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 Hereford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Castro County Nursing & Rehabilitation | 20.3 mi | ★★★★★ | 2 | 0 |
| Country View Living | 20.6 mi | ★★★★★ | 4 | 0 |
| Prairie Acres | 21.2 mi | ★★★★★ | 0 | 0 |
| Hillside Heights Rehabilitation Suites | 35 mi | ★★★★★ | 10 | 0 |
| Five Points Nursing And Rehabilitation | 37.6 mi | ★★★★★ | 7 | 1 |
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