20 health deficiencies
Top issue: Administration (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Converse, TX
1-star overall rating with 2-star inspections with $64,590 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
7700 Mesquite Pass, Converse, TX
(210) 650-0551
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
100
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-02-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.22
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.46
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.61
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.29
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
2.87
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
88%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
13,271
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 63.49% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.40
Baseline 3.61 hours · Performance 3.47 hours · Measure score 1.40 · Achievement 1.40 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.9% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 12.5% · Lower 95% interval 6.93% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 85.71% |
95.27%
9.6 pts worse
|
Numerator 36 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 42 · Adjusted rate 2.08% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.14% |
8.2%
1.1 pts worse
|
Numerator 4 · Denominator 56 |
| Staff flu vaccination coverage | 27.59% |
42%
14.4 pts worse
|
Numerator 16 · Denominator 58 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.1
1.1 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
97.9%
0.3 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.3%
2.8 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
3.3%
0.5 pts worse
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 14.3% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
18.9%
7.1 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 26.2% · Q3 29.3% · Q4 22.5% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
10.8%
7.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.7% · Q3 0.0% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.3% |
15.4%
4.1 pts better
|
16.3%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
16.1%
1.3 pts better
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 12.8% · Q3 16.2% · Q4 18.9% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
0.8%
0.2 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.1% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
15.0%
4 pts worse
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 35.9% · Q2 9.4% · Q3 9.1% · Q4 20.1% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.7% · Q3 3.7% · Q4 2.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
89.7%
5 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 96.0% · Q3 96.1% · Q4 91.1% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
12.0%
3.6 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 17.2% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
88.0%
4.2 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
25.9%
1.2 pts better
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 24.1% · Expected 23.3% · Used in QM five-star |
Survey summary
Top issue: Administration (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Assessment and Care Planning (7 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-04-04
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-09
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-30
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-09
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-30
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-14
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-04
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-08
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-03-25
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-15
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-13
Inspection history
Health
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.
Corrected 2025-09-07
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-07
Health
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.
Corrected 2025-04-07
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-04-22
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-04-22
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-04-22
Health
Provide training in compliance and ethics.
Corrected 2025-04-22
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-04-22
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-04-22
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-10
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-04-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-08
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-10
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-04-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-10
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-30
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-23
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-01
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-07-28
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-10
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-10
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-10
Health
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.
Corrected 2024-04-10
Health
Honor 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.
Corrected 2024-03-22
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-03-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-22
Health
Honor 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.
Corrected 2024-03-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-22
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-25
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-03-25
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-22
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-09-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-10
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-01-11
Penalties and ownership
Fine · fine $23,845
Fine
Fine · fine $15,440
Fine
Fine · fine $25,305
Fine
Payment Denial · denial start 2024-03-26 · 15 days
15 day denial
Operational/Managerial Control · Organization
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
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