Tierra Rose Care Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

How full it usually is: this home is certified for 76 beds and averages 71.0 residents a day — about 93% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.88 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.64 hrs/resident/day on weekends vs 5.36 on weekdays — 14% thinner on weekends. RN hours go from 0.51 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.

• Potential for harm · D2025-10-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review it was determined the facility failed to implement interventions to promote wound healing for 1 of 2 sampled residents (#5) reviewed for pressure ulcers. This placed the residents at risk for worsening pressure ulcers. Findings include: Resident 5 was admitted to the facility in 2024 with diagnoses including dementia. An 8/3/25 Significant Change MDS indicated Resident 5 was not cognitively intact and was at high risk for developing sores. Resident 5 was on a turning/repositioning program.An 8/22/25 Care Plan indicated the following:- Resident 5 required limited assistance by one staff to turn and reposition in bed two to three times a shift and as necessary. - Resident 5 was assisted to reposition often to reduce the risk of pressure related skin breakdown. - Staff were to follow facility policies/protocols for the prevention/treatment of skin breakdown. An 10/5/25 physician order indicated Resident 5 had a MASD (Moisture-Associated Skin Damage) wound in her/his coccyx. From 10/13/25 through 10/16/25, on eleven occasions between…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-17 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to follow infection control procedures for hand hygiene and PPE use for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infection and cross contamination. Findings include: 1. The CDC's 6/24/24 Infection Control Guidance: SAS-CoV-2 indicated staff who provided care to residents with confirmed COVID-19 were to wear a respirator with N95 filters and a barrier face covering. Resident 39 was admitted to the facility in 9/2/25 with a diagnosis of Parkinson's disease. A review of Resident 39's Progress Notes revealed she/he tested positive for COVID-19 on 10/14/25 at 10:23 AM. On 10/14/25 at 12:25 PM Resident 39's room was observed to have contact and droplet precaution signage on the door. On 10/14/25 at 12:25 PM Staff 12 (CNA) donned a gown, gloves, and surgical mask, but did not don eye protection and a N95 respirator before entering Resident 39's room. Staff 12 stated Resident 39…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-06-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview it was determined the facility failed to ensure food was stored appropriately and discarded in a timely manner, and failed to maintain a clean freezer for 1 of 1 kitchen and 1 of 1 resident refrigerator reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On 6/24/24 at 7:48 AM during the initial tour of the facility's walk-in refrigerator and walk-in freezer the following was observed: Walk-in refrigerator: *An opened half-gallon heavy whipping cream container with a manufacturer use by date of 6/3/24. *A red and brown liquid approximately 60 inches in length on the floor directly under a metal rack with food items including raw meat defrosting. Walk-in freezer: *An opened bag of pre-made egg and cheese omelets, undated. *Food crumbs and small dirt clumps approximately one centimeter and smaller on the floor throughout the entire freezer. On 6/24/24 at 8:05 AM Staff 6 (Dietary Manager) acknowledged the identified findings. 2. On 6/27/24 at 12:54 PM the resident refrigerator located in the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-06-28 · tag F0908 — failed to keep essential equipment working — pattern
  Keep all essential equipment working safely.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview, and record review it was determined the facility failed to maintain essential kitchen equipment in a safe operating condition for 1 of 1 kitchen reviewed for kitchen services. Findings include: On 6/24/24 at 7:48 AM an observation of the walk-in freezer in the kitchen revealed long vertical ice crystals approximately 15 inches in length attached to a pipe that connected to the freezer temperature unit. On 6/24/24 at 8:05 AM Staff 6 (Dietary Manager) acknowledged the identified findings. He stated the facility had two repair companies look at the walk-in freezer and each were unsuccessful with repairs. Staff 6 stated Staff 7 (Plant Manager) broke the ice crystals in the walk-in freezer weekly as the ice crystals accumulated rapidly and a log of this was kept. On 6/26/24 at 9:25 AM Staff 6 provided the facility's Kitchen Freezer Maintenance log and it revealed Staff 7 completed weekly maintenance in the walk-in freezer related to the ice crystals since 9/2023.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-28 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot care.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 3 sampled residents (#66) reviewed for ADLs. This placed residents at risk for lack of nail care and skin impairments. Finding include: Resident 66 admitted to the facility in 2024 with diagnoses including heart failure and weakness. Resident 66's 5/7/24 care plan indicated staff were to check nail length, trim and clean on bath days and as necessary and report any changes to the nurse. On 6/25/24 at 9:33 AM Resident 66 was observed wearing sandals and had thick toenails extending past the end of her/his toes. The 6/26/24 bathing records indicated Resident 66 had a bath on 6/26/24 at 11:52 AM. On 6/26/24 at 2:22 PM Staff 4 (CNA) stated nail care was to be provided to residents weekly and the nurse was responsible for giving CNA staff a list of who needed nail care. On 6/26/24 at 2:30 PM Staff 5 (LPN) observed Resident 66 and confirmed Resident 66's toenails were long, thick, and extended past the end of her/his toes.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-06-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review it was determined the facility failed to follow care planned interventions and revise care plans to prevent falls for 3 of 6 sampled residents (#s 1, 64 and 66) reviewed for falls and during a random observation. This placed residents at risk for injury from falls. Findings include: 1. Resident 64 admitted to the facility in 2024 with diagnoses including stroke and dementia. a. The 3/1/24 care plan indicated Resident 64 was to have a fall mat on the left side of the bed. Resident 64's 6/10/24 fall investigation indicated the following: - Resident 64 had dementia and a history of falls. - Resident 64 had a non-injury fall. The Resident was found on the right side of her/his bed and stated she/he attempted to transfer to the wheelchair and fell. -Resident 64 had weakness and balance issues and overestimated the ability to transfer independently. Though the call light was in reach, the resident had poor safety awareness as evidenced by all of her/his previous falls and chose to attempt to transfer and fell. Ongoing resident education on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-28 · tag F0761 — failed to label and store drugs safely — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review it was determined the facility failed to ensure proper storage and labeling of medication and biologicals for 1 of 2 medication carts and 1 of 1 medication and biologicals refrigerator reviewed for biologicals and medication storage. This placed residents at risk for inaccurate tuberculosis testing, decreased vaccine efficacy, improper medication administration, and reduced efficacy of medication. Findings include: According to the facility Medication Labeling and Storage Policy Statement, Revised 2/23, Multi-dose vials that are opened were dated and discarded within 28 days unless the manufacturer specified a shorter or longer date for the open vial. The policy also stated that medications may not be transferred between containers, and medications and biologicals were stored in the packaging, containers, or other dispensing systems in which they were received. On 6/26/24 at 10:15 AM a review of the biologicals and medication storage area was conducted with Staff 5 (LPN). One medication cart, and one refrigerator were reviewed for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 1 sampled resident (#7) reviewed for therapy services. This placed residents at risk for inaccurate medical records and unassessed needs. Findings include: Resident 7 was admitted to the facility in 4/2024 with diagnoses including arthritis, gait and mobility abnormalities and muscle weakness. Resident 7's Comprehensive Care Plan, dated 5/29/24, indicated the resident had an ADL self-care performance deficit. Interventions included the provision of a restorative nursing program with range of motion exercises for the resident's lower extremities. Resident 7 did not have active orders for Physical Therapy, Occupational Therapy, or Restorative Aid Therapy. On 6/26/24 at 12:55 PM Resident 7 stated she/he did not receive any therapy services or Restorative Aid Therapy services since her/his admission. On 6/26/24 at 1:46 Staff 13 (CNA/RA) stated Resident 7 was not receiving Restorative Aid Therapy at this time. On 6/27/24 at 1:49 PM Staff 15…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-04-21 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to attain and maintain the highest practicable well-being for 3 of 3 halls (100, 200, 300) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Interviews with residents revealed the following concerns: -On 4/17/23 at 10:53 AM Resident 23 stated call light response times could take over an hour during shift change especially when staff were leaving the night shift and day shift was beginning their shift. -On 4/17/23 at 11:03 AM Resident 63 stated right after lunch and shift change was difficult to receive assistance. Resident 63 indicated call light response times were 30 minutes or greater and she/he needed assistance with incontinence care, emptying of her/his urinal or adjusting the heat in her/his room. -On 4/17/23 at 11:10 AM Resident 43 stated call light response times were 30 minutes or greater and she/he used the call light to receive assistance…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-04-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review it was determined the facility failed to ensure residents received reasonable accommodation of needs for 1 of 1 sampled resident (#62) reviewed for accommodation of needs. This placed residents at risk for being dependent on bed mobility and repositioning in bed. Findings include: Resident 62 was admitted to the facility in 2/2022 with diagnoses including a stroke with left-sided weakness. The 2/2023 Annual MDS revealed Resident 62 was cognitively intact and required total two-person assistance with bed mobility. At 12:14 PM observed Resident 62 in bed attempting to use the bedrail to reposition herself/himself. Resident 62 stated she/he had a doctor's order for an over the bed trapeze bar to assist with repositioning and bed mobility. No trapeze bar was observed in Resident 62's room. Resident 62's 3/2023 physician's order revealed a trapeze bar for bed mobility order dated 2/22/22. On 4/19/23 at 2:30 PM Staff 3 (RNCM) stated she was aware Resident 62 had an order for a trapeze bar and thought the trapeze bar was ordered sometime in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in OR