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Western Hills Healthcare Residence
400 Old Sidney Rd, Comanche, TX 76442 · CMS Certification Number (CCN) 455602
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 30 in the last 3 inspection cycles (3 immediate jeopardy, 0 actual harm, 18 from complaints)
- Fire safety citations
- 12
- Fines (last 3 years)
- 1 fine, total $62,078
- Payment denials
- 1
- Most recent standard inspection
- May 14, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★★★☆☆ 3 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | May 14, 2025 | 7 | 6 | 2 |
| Cycle 2 | March 25, 2024 | 16 | 16 | 16 |
CMS weighted health inspection score: 146.25 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
30 health citations across 4 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
June 29, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0838 | 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. Administration Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/22/2026 |
May 14, 2025: 6 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0849 | 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. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/15/2025 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/15/2025 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/15/2025 |
| E | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/15/2025 |
| D | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 05/15/2025 |
| D | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/15/2025 |
March 25, 2024: 16 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| E | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/26/2024 |
| E | F-0803 | 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. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| D | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| K | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/12/2024 |
| E | F-0758 | 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. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/17/2024 |
| E | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/17/2024 |
| K | F-0726 | 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. Nursing and Physician Services Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/12/2024 |
| E | F-0712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| E | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| E | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/15/2024 |
| E | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/26/2024 |
| K | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/12/2024 |
February 8, 2023: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/09/2023 |
| E | F-0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/09/2023 |
| F | F-0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/09/2023 |
| D | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/09/2023 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/09/2023 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/09/2023 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/09/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
12 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 05/14/2025 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 06/15/2025 |
| 05/14/2025 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/15/2025 |
| 05/14/2025 | E | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/15/2025 |
| 03/25/2024 | F | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2024 |
| 03/25/2024 | F | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2024 |
| 03/25/2024 | F | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2024 |
| 03/25/2024 | F | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2024 |
| 03/25/2024 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2024 |
| 03/25/2024 | F | K-0344 | Have an alternate power supply for its alarm system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2024 |
| 03/25/2024 | F | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2024 |
| 03/25/2024 | F | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 04/15/2024 |
| 02/08/2023 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 03/09/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| March 25, 2024 | Fine | $62,078 | — |
| March 25, 2024 | Payment Denial | — | Starting April 24, 2024, 15 days |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.56 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.29 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.05 | Not published | Not published |
| Nurse aide hours per resident per day | 2.22 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.14 | Not published | Not published |
| RN hours per resident per day, weekends | 0.23 | Not published | Not published |
| Total nursing staff turnover (%) | 52.1 | 55.3 | 45.8 |
| Registered nurse turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Coryell County Memorial Hospital Authority
- Ownership type
- For profit - Limited Liability company
- Chain
- Coryell County Memorial Hospital Authority (9 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 158
- Average residents per day
- 54.2
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- November 14, 1985
- County/parish
- Comanche
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
6 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| BYROM, DAVID | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TGR HEALTHCARE, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THOMAS, BRIAN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TGR HEALTHCARE, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THOMAS, BRIAN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Western Hills Healthcare Residence. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.