01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-14 | 7 | 2025-05-14 | 3 |
| Cycle 2 | 2024-03-25 | 16 | 2024-03-25 | 8 |
| Cycle 3 | 2023-02-08 | 7 | 2023-02-08 | 1 |
CMS CCN 4556022026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Western Hills Healthcare Residence
400 Old Sidney Rd · Comanche, TX 76442 · Comanche County
Certified beds158CMS provider file
Recent citation rows42current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
42 rows in the current release
3 rows carry G–L scope/severity codes; 3 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-29 · HEALTHF0838Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Correction field: Deficient, Provider has no plan of correction · complaint2025-05-14 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2025-05-152025-05-14 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Deficient, Provider has date of correction · 2025-05-15 · complaint2025-05-14 · HEALTHF0605Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has date of correction · 2025-05-152025-05-14 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-05-152025-05-14 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-05-152025-05-14 · HEALTHF0849Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Correction field: Deficient, Provider has date of correction · 2025-05-152025-05-14 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-06-152025-05-14 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-06-152025-05-14 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-06-152024-03-25 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2024-04-152024-03-25 · HEALTHF0580Severity K · pattern of immediate jeopardy
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2024-04-12 · complaint2024-03-25 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-03-26 · complaint2024-03-25 · HEALTHF0655Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2024-03-25 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2024-03-25 · HEALTHF0695Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2024-03-25 · HEALTHF0712Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2024-03-25 · HEALTHF0726Severity K · pattern of immediate jeopardy
Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Correction field: Deficient, Provider has date of correction · 2024-04-12 · complaint2024-03-25 · HEALTHF0756Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2024-04-17 · complaint2024-03-25 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Correction field: Deficient, Provider has date of correction · 2024-04-17 · complaint2024-03-25 · HEALTHF0760Severity K · pattern of immediate jeopardy
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-04-12 · complaint2024-03-25 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2024-03-25 · HEALTHF0770Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2024-03-25 · HEALTHF0803Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-03-25 | Fine | $62,078 | 0 |
| 2024-03-25 | Payment Denial | $0 | 15 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BYROM, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2014
- CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITYOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2019
- TGR HEALTHCARE, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2019
- THOMAS, BRIANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2019
- TGR HEALTHCARE, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/18/2025
- THOMAS, BRIANIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2019
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.56per resident day
RN hours0.29per resident day
Weekend nurse hours3.14per resident day
Staff turnover52.1%CMS reported field
06 / LOCAL RECORDS
Open the Comanche ledger →