Cycle 1
Health 2024-11-07 · Fire 2024-11-07
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Lampasas, TX
Caraday Of Lampasas
4-star overall rating with 4-star inspections with $16,426 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1000 E Ave J, Lampasas, TX
(512) 556-6267
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
52
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Caraday Healthcare
Operator or chain grouping
Approved since
2019-11-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
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
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,722
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
3.82
Performance 6.69% · Measure score 3.82 · Achievement 3.82 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.31
Performance 58.33% · Measure score 1.31 · Achievement 1.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.69
Baseline 4.98 hours · Performance 3.56 hours · Measure score 1.69 · Achievement 1.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 6.08% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.87 |
1.02
0.9 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 65.52% |
8.2%
57.3 pts better
|
Numerator 38 · Denominator 58 |
| Staff flu vaccination coverage | 58.54% |
42%
16.5 pts better
|
Numerator 48 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.7 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.3 |
2.1
2.2 pts worse
|
1.8
2.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 3.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.6% |
3.3%
4.3 pts worse
|
3.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 8.2% · Q3 8.2% · Q4 9.8% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
2.7%
0.9 pts worse
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.4% · Q3 4.7% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
3.3%
0.9 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.5% · Q3 2.5% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
18.9%
2.1 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.7% · Q3 15.9% · Q4 17.8% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
10.8%
1.9 pts worse
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 10.3% · Q3 10.0% · Q4 14.3% · 4Q avg 12.7% · 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 | 14.0% |
15.4%
1.4 pts better
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 23.6% · Q3 4.2% · Q4 10.3% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
16.1%
3.7 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 11.1% · Q3 12.5% · Q4 19.5% · 4Q avg 12.4% · 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 | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
15.0%
1 pts worse
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 15.4% · Q3 14.3% · Q4 20.3% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.2%
0.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.6% · Q4 8.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
89.7%
7.2 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 100.0% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.8% |
12.0%
17.8 pts worse
|
12.0%
17.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 29.2% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.1% |
25.9%
8.2 pts worse
|
23.9%
10.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.1% · Observed 29.2% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-06-14 · Fire 2022-06-14
1 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-06
C · Minimal harm
2024-11-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-28
C · Minimal harm
2023-09-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
F · Potential for more than minimal harm
2022-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-03
E · Potential for more than minimal harm
2022-06-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-03
E · Potential for more than minimal harm
2022-06-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-20
C · Minimal harm
2022-06-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-23
G · Actual harm
2024-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-11-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-11-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-11-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-08
H · Actual harm
2024-03-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-29
G · Actual harm
2023-09-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-16
F · Potential for more than minimal harm
2023-09-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-16
D · Potential for more than minimal harm
2023-09-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-09-16
D · Potential for more than minimal harm
2023-09-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-16
D · Potential for more than minimal harm
2023-09-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-16
D · Potential for more than minimal harm
2022-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-06
Penalties and ownership
What sits behind the stars
$2,243
2024-11-07
Fine
Fine · fine $2,243
Fine
$10,829
2024-03-06
Fine
Fine · fine $10,829
Fine
$3,354
2023-09-14
Fine
Fine · fine $3,354
Fine
Ownership
Stratford Hospital District
5% Or Greater Direct Ownership Interest · Organization
Caraday Lampasas LLC
Operational/Managerial Control · Organization
Chumley, Richard
Corporate Director · Individual
Hoss, Ralph
Operational/Managerial Control · Individual
Moore, Gregory
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lampasas Nursing and Rehabilitation Center
Lampasas, TX
1-star overall rating with 2-star inspections with $11,440 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Lily Springs Rehabilitation and Healthcare Center
Lampasas, TX
1-star overall rating with 1-star inspections with $100,728 in total fines with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Copperas Cove Nursing & Rehabilitation
Copperas Cove, TX
2-star overall rating with 2-star inspections with $31,990 in total fines with 15 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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