Map showing the location of ARBOR TERRACE HEALTHCARE CENTER in SAN ANGELO, Texas
609 RIO CONCHO DR, SAN ANGELO, TX, 76903

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasLowest tier among peers1,167 rated homes · average 2.8★
  • Tom Green CountyLowest tier among peers7 rated homes · average 2.7★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs TX avg
  • StaffingCan add or remove a star1★−1.1 vs TX avg
  • Quality measuresCan add or remove a star4★+0.2 vs TX avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersTX avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 37% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.24hrsAbove only 44% of peersTX avg3.40Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.23hrsAbove only 12% of peersTX avg0.44Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better69%Above only 12% of peersTX avg51%RN turnover82%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$121,840Above only 15% of peersTX avg$55,368Fines · denials3 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
40citations
12inspection dates
0actual harm (G–I)
3immediate jeopardy (J–L)
Nov 18, 2025most recent

Citations by monthOct 2022 – Nov 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Nov 18, 20251 citationCycle 1worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 31, 2025
May 22, 20252 citationsCycle 1worst D · no actual harm
  1. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jun 2, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 2, 2025
Feb 7, 202510 citationsCycle 1worst E · no actual harm
  1. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Feb 28, 2025
  2. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Feb 28, 2025
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 28, 2025
  4. F761Ensure 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 ServiceE · patternCorrected Feb 28, 2025
  5. F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Feb 28, 2025
  6. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 28, 2025
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Feb 28, 2025
  8. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Feb 28, 2025
  9. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Feb 28, 2025
  10. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 28, 2025
Nov 20, 20242 citationsCycle 2worst D · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Dec 20, 2024
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Dec 20, 2024
Aug 10, 20241 citationCycle 2worst K · immediate jeopardy$68,572
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceK · patternCorrected Aug 11, 2024
Mar 29, 20247 citationsCycle 2worst K · immediate jeopardy
  1. F656Develop 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 PlanningD · isolatedCorrected Mar 30, 2024
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Mar 30, 2024
  3. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Mar 30, 2024
  4. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Mar 30, 2024
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected Mar 30, 2024
  6. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Mar 30, 2024
  7. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 30, 2024
Feb 29, 20241 citationCycle 2worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Mar 15, 2024
Jan 4, 20244 citationsCycle 2worst F · no actual harm$37,999
  1. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Jan 31, 2024
  2. F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesE · patternCorrected Jan 31, 2024
  3. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Jan 31, 2024
  4. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jan 31, 2024
Dec 1, 20231 citationCycle 3worst J · immediate jeopardy$15,269
  1. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareJ · isolatedCorrected Nov 26, 2023
Sep 29, 20231 citationCycle 3worst D · no actual harm
  1. F761Ensure 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 ServiceD · isolatedCorrected Oct 15, 2023
Jul 9, 20232 citationsCycle 3worst D · no actual harm
  1. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Jul 26, 2023
  2. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Jul 26, 2023
Oct 26, 20228 citationsCycle 3worst F · no actual harm
  1. F886Perform COVID19 testing on residents and staff.Infection ControlE · patternCorrected Nov 17, 2022
  2. F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsE · patternCorrected Nov 17, 2022
  3. F656Develop 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 PlanningD · isolatedCorrected Nov 17, 2022
  4. F761Ensure 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 ServiceE · patternCorrected Nov 17, 2022
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 17, 2022
  6. F814Dispose of garbage and refuse properly.Nutrition and DietaryC · widespreadCorrected Nov 17, 2022
  7. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 17, 2022
  8. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected Nov 17, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.24hrsAbove only 44% of peers−0.16 vs TX avg
  • Registered nursesRN hours only0.23hrsAbove only 12% of peers−0.21 vs TX avg
  • Licensed practical nursesLPN hours1.07hrs
  • Nurse aidesCNA hours1.95hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.94hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better69%Above only 12% of peersTX avg 51%
  • RN turnoverRegistered nurses only82%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy126 certified beds · ~69 residents a day55%Above only 25% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $121,840In fines
  • 3Fines
  • 0Payment denials
  • $55,368TX avg in fines
Above only 15% of peersFewer fines than 15% of rated homes in Texas

Actions on record

  1. Aug 10, 2024Civil money penalty$68,572
  2. Jan 4, 2024Civil money penalty$37,999
  3. Dec 1, 2023Civil money penalty$15,269

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Slp Operations27 facilities in the chain2.6★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Stratford Hospital District
Operational or managerial control
  • Slp San Angelo, LLC
  • Joshua Leonard
Corporate directors
  • Richard Chumley
Mortgage or security interest (5%+)
  • Carlisle Taylor Whitworth 2020 Irrevocable Trust
  • Gary Scott Whitworth 2019 Irrevocable Trust
  • Lqcp Management, LLC
  • Wm 41 San Angelo Re, LLC
  • Wm-Lqc Mm, LLC
  • Wt Holdings, LP

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 675932 · 609 RIO CONCHO DR, SAN ANGELO, TX, 76903.
  • Percentiles compare this facility with every rated nursing home in Texas and Tom Green County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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