Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage House Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with quadriplegia, morbid obesity, multiple chronic conditions, and full dependence for bed mobility was care planned for Hoyer lift transfers requiring two staff. During a transfer from lift to bed, one CNA independently operated the Hoyer lift despite posted signage requiring at least two staff and facility policy tying staffing to manufacturer recommendations. The second CNA had briefly left the room to obtain larger gloves and returned after the resident was already lowered into bed. Both CNAs, the DON, and the Administrator acknowledged that two trained staff were required for Hoyer transfers and that the CNA who operated the lift alone had been trained and was experienced.
A facility failed to provide prompt grievance resolution for 3 of 3 confidential residents interviewed. A binder near the nurse's station contained outdated grievance forms and an outdated contact list that did not identify the current grievance official, ADM, or DON, and staff said the binder was not used. Residents reported they had to get a grievance form from staff, did not recall receiving written grievance resolutions, and the SW stated written responses were only provided if a resident asked. The ADM and CRN confirmed residents had the right to file anonymous grievances and receive written resolutions, while the facility policy required prominent postings and written grievance decisions.
Food Items Improperly Labeled and Stored: Surveyors found multiple food items in coolers, freezers, and a pantry that were not properly labeled with open or expiration dates, had past use-by dates, or were spoiled, including brown celery, rotten potatoes, and a container of flour with an expired use-by date. The RDM, DM, and ADM stated that kitchen staff were responsible for checking dates and discarding out-of-date items, and the facility policy required food to be dated when received and expired items to be discarded.
The facility did not complete or document required PASRR Level I screenings or make referrals for Level II evaluations for three residents with new or existing serious mental disorders, despite new psychiatric diagnoses and changes in condition. Staff interviews revealed gaps in knowledge about PASRR requirements, and facility policy was not consistently followed.
Two residents did not have their comprehensive care plans updated and revised by the interdisciplinary team after changes in their condition or physician orders. One resident's care plan continued to include smoking-related interventions after he had quit smoking, and another resident's care plan did not reflect current physician orders for weights. Staff interviews revealed confusion about responsibility for updating care plans, and the facility's policy for timely care plan updates was not consistently followed.
The facility did not consistently obtain accurate weights or monitor significant weight changes for several residents with complex medical conditions, resulting in unaddressed weight loss or gain. Care plans often lacked specific goals or interventions, and there were instances where physicians or dietitians were not notified of substantial weight variances. Surveyor observations also found discrepancies in recorded weights and a lack of resident awareness regarding their weight status.
Staff failed to perform proper hand hygiene and sanitize a blood pressure cuff between residents during medication administration. A medication aide was observed using the same BP cuff on multiple residents without cleaning it and did not sanitize hands between resident contact and medication preparation. Staff interviews and facility policy confirmed that hand hygiene and equipment cleaning were required between residents to prevent infection.
A resident with cerebral infarction was burned by hot coffee in an LTC facility. The coffee machine was accessible to all residents, and the coffee temperature was consistently 140 degrees. The resident, who could only use one arm, attempted to get coffee independently and spilled it, resulting in a burn. Staff interviews confirmed the coffee temperature was intended to be 140 degrees to prevent burns, but the incident highlighted a lapse in supervision.
Single-Staff Operation of Hoyer Lift Contrary to Two-Person Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of assistive devices during a mechanical lift transfer for one resident. The resident was an adult female with epilepsy, morbid obesity, type 2 diabetes, chronic kidney disease, an unspecified bone disorder, heart failure, unspecified psychosis, major depressive disorder, and quadriplegia. Her MDS showed a BIMS score of 15, indicating little to no cognitive impairment, and documented that she used a manual wheelchair and was dependent on staff for bed mobility. Her care plan, last reviewed on 2/11/2026, required use of a Hoyer lift for transfers with an intervention specifying that all Hoyer transfers were to be performed by two staff members. The facility’s hydraulic lift policy stated that the number of staff to provide assistance should be determined by manufacturer recommendations. On the survey date, an observation showed CNA A standing to the left of the resident’s bed and independently lowering the resident into bed using the Hoyer lift. A sign on the lift in the room stated that at least two staff members must assist during use of the lift. CNA B entered the room only after the resident had been lowered into bed and placed a box of gloves on the bed. CNA A acknowledged knowing that two staff members were required for Hoyer transfers and stated she was waiting for CNA B, who had gone to get larger gloves, and that they wanted to complete the transfer before lunch trays arrived. CNA B confirmed she had been trained that two staff were required for Hoyer transfers and stated she did not know why CNA A operated the lift alone. The DON and Administrator both stated that two trained staff members were supposed to operate the Hoyer lift and that CNA A had been trained and worked at the facility for many years.
Grievance Process Lacked Current Postings and Written Resident Resolutions
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for 3 of 3 confidential residents interviewed regarding their right to file grievances. During an observation and interview, a white binder titled Grievance Forms was seen affixed to a wall near the nurse's station, but the contact list inside was outdated and did not include the current grievance official, current ADM, current DON, or other current facility staff. The grievance forms in the binder were also outdated, and the SW stated the facility did not use that binder. In confidential interviews, the residents who had filed grievances did not recall receiving written resolutions to their grievances, and not all recalled receiving verbal resolutions. Some stated their grievances had improved, but all said they had to obtain a grievance form from a staff member at the facility. The SW stated residents could go to her office to get and submit a grievance form, that she was the grievance official, and that she did not provide written responses unless a resident asked. The ADM and CRN stated residents had the right to file an anonymous grievance and receive a written resolution, and the facility policy required prominent postings, anonymous filing options, and written grievance decisions.
Food Items Improperly Labeled, Dated, and Stored
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in its kitchen. During observations, surveyors found multiple food items that were not properly labeled or dated, including bacon in a zip top bag without an expiration date, celery that was brown and dated 1-06 with no expiration date, pancakes and sausage with biscuits in the freezer without open or expiration dates, and several items in a second cooler that were either unlabeled or had dates that were past the listed use-by date. Surveyors also observed beef patties, pork chops, meatballs, tamales, chicken, and pizza dough in the freezer that were not properly labeled with open or expiration dates, along with rotten potatoes in a pantry that were sprouting and soft to the touch and had no use-by date. A clear container of flour was also found with a use-by date of 11-11-25. Interviews with the RDM, DM, and ADM showed that all kitchen staff were responsible for checking dates and labeling food items, and that out-of-date items should be discarded. The RDM stated coolers should be checked daily and freezers weekly, and that staff received training on dating food items and handling out-of-date items. The facility’s Dietary Services Policy & Procedure Manual stated that products without a dated shipping label should be dated when received, items with expiration dates should be marked clearly, and any product with a stamped expiration date should be discarded once that date passes.
Failure to Complete and Refer PASRR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to coordinate assessments and referrals as required by the Pre-Admission Screening and Resident Review (PASRR) program for three residents with newly identified or existing serious mental disorders. Specifically, the facility did not complete or document PASRR Level I screenings and did not refer residents for Level II evaluations when new diagnoses of mental illness were made or when significant changes in status occurred. For one resident, there was no evidence of a PASRR Level I or II form after a diagnosis of bipolar disorder was added, despite the presence of other psychiatric diagnoses and ongoing treatment for depression. Another resident was admitted with diagnoses including Major Depressive Disorder and Unspecified Psychosis, and although a PASRR I screen was completed and marked negative, there was no evidence of further screening or referral after new psychiatric diagnoses were added. A third resident, who had multiple psychiatric diagnoses including schizoaffective disorder and bipolar disorder, had several PASRR I screenings, with the most recent one being positive for mental illness, but there was no PASRR II form found in the medical record. This resident was also receiving medication specifically for a mood disorder. Interviews with facility staff revealed a lack of awareness and understanding regarding the requirement to conduct PASRR screenings upon new psychiatric diagnoses or significant changes in resident status. The Director of Nursing was unaware that new diagnoses required additional screening, and the Clinical Registered Nurse confirmed that positive PASRR I results should lead to a referral for a Level II evaluation, which was not done. Facility policy required PASRR Level I screening prior to admission and referral for Level II evaluation if indicated, but this was not consistently followed.
Failure to Update and Revise Comprehensive Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, as required. Specifically, two residents were affected by this deficiency. One resident, a male with diagnoses including congestive heart failure, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, had quit smoking in July 2024. However, his care plan continued to reflect him as a smoker, with interventions and goals related to smoking still in place, despite his self-reported cessation and confirmation by the DON. Another resident, a female with diagnoses including unspecified protein-calorie malnutrition and congestive heart failure, had care plan interventions that did not accurately reflect her current physician orders regarding weights. Her care plan included monitoring and documenting meal intake and weights, as well as interventions for significant unplanned weight loss, but there were no current physician orders for weights, and the care plan was not updated to reflect this. Interviews with facility staff, including the DON, MDS nurse, and administrator, revealed a lack of clarity and responsibility regarding the process for updating care plans. The DON and administrator both stated that care plans should be updated in real time and reflect the resident's current condition, but the MDS nurse was unsure of her role in the process. The facility's policy requires ongoing assessment and updating of care plans when a resident's clinical status or condition changes, but this was not consistently followed for the residents reviewed.
Failure to Ensure Accurate Weight Monitoring and Nutritional Status
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, including usual or desirable body weight and electrolyte balance, for eight out of thirty-one residents reviewed. Surveyors found that the facility did not consistently obtain accurate resident weights, resulting in significant weight variances that were not always identified or addressed. In several cases, there were no medical orders for regular weight monitoring or clear parameters for when to notify a physician of weight changes. Additionally, care plans often lacked specific goals or failed to document effective interventions for residents experiencing significant or severe weight loss or gain. Multiple residents with complex medical histories, such as congestive heart failure, diabetes, COPD, cerebral palsy, and protein-calorie malnutrition, experienced substantial unplanned weight changes over periods ranging from one to six months. For example, one resident lost over 17% of body weight in three months, while another gained over 17% in a similar timeframe. In several instances, the documentation did not reflect that physicians or dietitians were notified of these significant weight variances, and there were gaps in progress notes or follow-up assessments. Some care plans were missing goals or had not been updated to reflect the residents' current nutritional risks or needs. Surveyor observations revealed discrepancies between facility-recorded weights and those obtained during the survey, further highlighting issues with the accuracy of weight monitoring. Interviews with residents indicated a lack of awareness regarding their weight changes, and some residents reported only being weighed monthly. The facility's failure to consistently monitor, document, and respond to significant weight changes placed residents with medical conditions at risk for changes in physical status.
Failure to Perform Hand Hygiene and Sanitize Equipment During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of improper hand hygiene and inadequate sanitization of equipment during medication administration for four residents. During medication passes, a medication aide (MA) was observed taking blood pressures using a blood pressure (BP) cuff, then returning the cuff to the medication cart without cleaning it between residents. The MA also failed to perform hand hygiene between taking residents' blood pressures and preparing or administering medications, and touched multiple surfaces on the medication cart and computer without sanitizing hands in between. The residents involved had various medical conditions, including epilepsy, depression, heart failure, hypertension, malnutrition, atrial fibrillation, right-side paralysis, stroke, anemia, and heart disease. Most of these residents were cognitively intact, as indicated by their BIMS scores, except for one whose score could not be determined. The care plans for these residents included interventions such as administration of anti-hypertensive and anti-depressant medications, which required direct care and contact. Interviews with facility staff, including a CNA, the administrator, the DON, and an RN, confirmed that facility policy required hand hygiene between residents and cleaning of equipment, such as BP cuffs, with sanitizer wipes between uses. The staff acknowledged the importance of these practices for infection control and preventing the spread of infectious diseases. A review of the facility's infection control policy further supported these requirements, specifying hand hygiene after contact with residents' skin and cleaning of non-invasive equipment between uses.
Resident Burned by Hot Coffee Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards, specifically regarding the temperature of coffee served to residents. Resident #3, who was admitted with a primary diagnosis of cerebral infarction, experienced a coffee spill incident that resulted in a burn wound on her right thigh. The nursing notes indicated that the resident had a large area of redness on her upper right inner thigh after the spill, and a cold compress was applied. The wound care physician later confirmed the presence of a burn wound. Observations revealed that the coffee machine in the dining room was accessible to all residents, and the coffee temperature was consistently recorded at 140 degrees. Interviews with staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), confirmed that the coffee temperature was intended to be maintained at 140 degrees to prevent burns. However, Resident #3, who was only able to use one arm, attempted to get coffee independently and spilled it on herself, leading to the burn. The facility's guidelines for serving coffee stated that the standard temperature should be 140 degrees unless residents preferred it hotter, with additional safety measures in place. Despite these guidelines, the incident occurred, highlighting a lapse in ensuring the safety of residents when handling hot beverages. The staff acknowledged the potential for burns if coffee was served too hot, and the incident with Resident #3 demonstrated the consequences of not adequately supervising residents with physical limitations when accessing hot liquids.
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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 Rosebud
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winnie L Nursing & Rehabilitation | 14.2 mi | ★★★★★ | 4 | 0 |
| Legacy Nursing And Rehabilitation | 14.2 mi | ★★★★★ | 8 | 0 |
| Golden Years Nursing And Rehabilitation Center | 16.8 mi | ★★★★★ | 0 | 0 |
| Bremond Nursing And Rehabilitation Center | 18.6 mi | ★★★★★ | 3 | 0 |
| William R Courtney Texas State Veterans Home | 22.1 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.