Glen Rose Nursing and Rehab Center
1019 Holden St, Glen Rose, TX 76043 · Somervell County · 118 certified beds · avg 89 residents/day · certified since Mar 22, 1996
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 11, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 24, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Jan 5, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 29, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (20)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 15, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 15, 2026 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jan 15, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 15, 2026 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jan 15, 2026 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Jan 15, 2026 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Nov 21, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 11, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 11, 2025 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 11, 2025 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Nov 21, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Oct 10, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Jan 5, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 13, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 13, 2023 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Sep 13, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 13, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 13, 2023 | C · Minimal risk, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | E |
| 2024 | 5 | 1 | G ▲ |
| 2025 | 4 | 1 | G ▲ |
| 2026 | 6 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $17,128.
| Date | Type | Amount / length |
|---|---|---|
| May 11, 2025 | Fine | $9,110 |
| Jan 5, 2024 | Fine | $8,018 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.86 | 3.46 | 3.95 | top 19% in Texas; top 46% in the U.S. |
| Registered Nurse hours | 0.30 | 0.44 | 0.69 | bottom 29% in Texas; bottom 10% in the U.S. |
| Weekend total nurse staffing | 3.17 | 3.04 | 3.50 | top 30% in Texas; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.34 | 0.48 | bottom 35% in Texas; bottom 20% in the U.S. |
| Total nursing staff turnover (%) | 37.8 | 55.3 | 45.8 | top 16% in Texas; top 31% in the U.S. |
| RN turnover (%) | 28.6 | 54.6 | 42.9 | top 15% in Texas; top 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.39, RN 0.27, weekend 2.78. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Somervell County Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/01/2021 |
| Glen Rose Nursing and Rehabilitation, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
| Honea, Michael | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2021 |
| Thomas, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
| Whitehead, Daniel | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "Where do you post your latest state inspection results and the ombudsman's contact information?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Cherokee Rose Nursing and Rehabilitation | 0.5 mi | Glen Rose, TX | ★★★☆☆ | 4/5 | |
| Granbury Rehab & Nursing | 13.1 mi | Granbury, TX | ★★☆☆☆ | 3/5 | |
| Harbor Lakes Nursing and Rehabilitation Center | 13.4 mi | Granbury, TX | ★★★★★ | 5/5 | |
| Granbury Care Center | 14.2 mi | Granbury, TX | ★☆☆☆☆ | 2/5 | |
| Avir at Granbury | 14.7 mi | Granbury, TX | ★☆☆☆☆ | 2/5 | |
| Ridgeview Rehabilitation and Skilled Nursing | 19.2 mi | Cleburne, TX | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675572.