Deficiency Index

Emory Health and Rehab

Emory, Texas · CCN 676142

29 surveys since 2011, 22 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
202
Surveys
29
Harm or worse
22
Immediate jeopardy
5
The record, 2011–2025
’11’15’20’25
No harm recordedHarm or worseNot surveyed
Immediate jeopardy5

Findings at the most serious level CMS records.

Beyond CMS’s monthly file26/29

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
68
Ownership
Government - Hospital district
Chain
Independent
County
Rains · rural
Medicare-certified since
2007

CMS ratings

Overall
3
Health inspection
4
Staffing
1
Quality measures
4

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.

Weighted by harm level, against 49 government-run facilities of 66–99 beds in Texas.

Last survey on record

Aug 5, 2025

461 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day2.853.24
Registered-nurse hours per resident day0.22—
Annual nurse turnover80.0%54.3%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ13.6%K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD1967.9%E414.3%F27.1%
No harm, potential for minimalA—B—C27.1%
CMS’s current file: 28 of the 202 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F5802×

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • F6562×

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

  • F6892×

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

  • F6952×

    Provide safe and appropriate respiratory care for a resident when needed.

  • F7612×

    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.

In the surveyor’s words

From the most serious findings on record at Emory Health and Rehab, in the surveyor’s own words.

  • Immediate jeopardy, isolatedF689May 10, 2023

    Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 2 of 14 residents (Resident #17 and Resident #184) reviewed for accidents hazards from hot coffee. The facility failed to ensure safety measures were in place after Resident #184 received a second-degree burn (burns that involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful) from hot coffee that required treatment. The facility failed to ensure safety measures were in place to prevent Resident #17 from obtaining an injury from hot coffee. An Immediate Jeopardy (IJ) situation was identified on 05/09/23. […]

  • No harm, potential for more than minimal, widespreadF812Jul 10, 2024

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were labeled and dated. 2. Hair restraints worn. 3. The microwave was clean and free of food debris. 4. The toaster was clean and free of food debris. 5. Expired food item was discarded. 6. Refrigerator/Freezer log was kept up to date. 7. Personal drinks were kept out of facility refrigerator. These failures could place residents at risk for foodborne illness. Findings included: During an observation and interview on [DATE] at 8:00 a.m., [NAME] C was in the kitchen without wearing a hair restraint. […]

  • No harm, potential for more than minimal, widespreadF812May 10, 2023

    Based on observation, interview, and record review, the facility failed to ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving. The facility did not ensure hair restraints were worn appropriately by Dietary Cook C and Cook D while they prepared and served residents' food. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 05/07/23 at 11:49 a.m., Cook C was not wearing a hair restraint appropriately while serving the lunch meal. […]

  • No harm, potential for more than minimal, patternF584Jul 10, 2024

    Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 4 of 4 resident's (Resident #'s 4, 17, 25, and 34) reviewed for a homelike environment. The facility failed to ensure Resident #25's wall behind her bed was free from deep gouges into the sheetrock measuring 4 inch wide and 2 feet long. The facility failed to ensure Resident #17's and Resident #34's bed linens were changed. The facility failed to ensure Resident #34 had hot water available in the bathroom. The facility failed to ensure Resident #34 had a toilet seat that was free from peeling paint. The facility failed to ensure Resident #34's toilet was flushing properly. […]

  • No harm, potential for more than minimal, patternF677Jul 10, 2024

    Based on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 4 residents (Resident #'s 140 and 17) reviewed for ADLs. The facility failed to ensure Resident #140's face was free from facial hair. The facility failed to ensure Resident #17 received routine scheduled showers. These failures could place residents at risk for not receiving services/care and a decreased quality of life. 1) Record review of a face sheet dated 6/10/2024 indicated Resident #140 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of profound intellectual disabilities (the inability to live alone, and care for themselves). […]

Read 41 findings in full →The most serious and the most recent: 41 of 202 on record.

Every survey on record

FindingsAt actual harm or above

  • Aug 5, 2025Standard5 findings
  • Jul 10, 2024Standard11 findings
  • May 10, 2023Standard12 findings · 1 harm
  • Mar 30, 2022Standard12 findings
  • Jun 10, 2021Standard6 findings
  • Dec 2, 2020Infection control1 finding · 1 harm
  • Nov 4, 2020Infection control2 findings · 2 harm
  • Feb 11, 2020Standard11 findings
Show the 21 earlier surveys
  • Jun 14, 2019Complaint1 finding
  • Feb 27, 2019Standard7 findings
  • Nov 1, 2018Complaint3 findings
  • May 17, 2018Complaint1 finding
  • Mar 23, 2018Standard14 findings
  • Sep 27, 2017Complaint1 finding · 1 harm
  • May 1, 2017Complaint2 findings · 2 harm
  • Mar 15, 2017Standard and complaint15 findings
  • Nov 28, 2016Complaint1 finding · 1 harm
  • Nov 2, 2016Complaint3 findings
  • Mar 22, 2016Complaint2 findings · 2 harm
  • Feb 20, 2016Standard and complaint18 findings · 4 harm
  • Mar 25, 2015Complaint1 finding
  • Jan 21, 2015Standard and complaint8 findings · 1 harm
  • Jan 5, 2015Complaint2 findings
  • Feb 20, 2014Standard14 findings
  • Apr 30, 2013—4 findings
  • Mar 13, 2013Standard24 findings · 6 harm
  • Oct 18, 2012—1 finding
  • Mar 7, 2012—16 findings · 1 harm
  • Mar 23, 2011—4 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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