Columbus, TX

Columbus Oaks Healthcare Community

3-star overall rating with 3-star inspections with $9,750 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

300 North St, Columbus, TX

(979) 732-2347

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

137

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Dynasty Healthcare Group

Operator or chain grouping

Approved since

2003-12-08

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

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

0.74

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.74

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.05

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.54

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.48

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.98

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.46

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.92

CMS adjusted RN staffing hours

Adjusted total hours

4.38

CMS adjusted total nurse staffing hours

Case-mix index

1.10

Higher values indicate more complex resident acuity

RN turnover

44%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,801

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

28.72

Composite VBP score used to determine payment impact.

Payment multiplier

0.9851

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.28

Performance 19.45% · Measure score 4.28 · Achievement 4.28 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

2.29

Performance 7.15% · Measure score 2.29 · Achievement 2.29 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

2.76

Baseline 52.78% · Performance 52.38% · Measure score 2.76 · Achievement 2.76 · Improvement 0

Adjusted total nurse staffing

2.15

Baseline 3.23 hours · Performance 3.69 hours · Measure score 2.15 · Achievement 2.15 · Improvement 1.32

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.94%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 7.08%
Discharge to community	43.39%	50.57% 7.2 pts worse	No Different than the National Rate · Eligible stays 33 · Observed rate 39.39% · Lower 95% interval 32.53%
Medicare spending per beneficiary	1.19	1.02 0.2 pts worse
Drug regimen review with follow-up	96.67%	95.27% 1.4 pts better	Numerator 29 · Denominator 30
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 30
Discharge self-care score	40%	53.69% 13.7 pts worse	Numerator 8 · Denominator 20
Discharge mobility score	45%	50.94% 5.9 pts worse	Numerator 9 · Denominator 20
Pressure ulcers or injuries, new or worsened	6.67%	2.29% 4.4 pts worse	Numerator 2 · Denominator 30 · Adjusted rate 6.76%
Healthcare-associated infections requiring hospitalization	7.15%	7.12% About the same	No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.66%
Staff COVID-19 vaccination coverage	3.03%	8.2% 5.2 pts worse	Numerator 3 · Denominator 99
Staff flu vaccination coverage	67.39%	42% 25.4 pts better	Numerator 62 · Denominator 92
Discharge function score	50%	56.45% 6.5 pts worse	Numerator 10 · Denominator 20
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · 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	2.6	2.1 0.5 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.8	2.1 0.7 pts worse	1.8 1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.5 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	97.1% 2.5 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.7%	97.9% 0.8 pts better	95.5% 3.2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7%
Percentage of long-stay residents experiencing one or more falls with major injury	8.5%	3.3% 5.2 pts worse	3.3% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 6.9% · Q3 7.1% · Q4 10.5% · 4Q avg 8.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	2.7% 2.7 pts better	11.4% 11.4 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 who lose too much weight	6.2%	3.3% 2.9 pts worse	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 4.9% · Q3 6.7% · Q4 4.6% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.3%	18.9% 1.4 pts worse	19.6% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.7% · Q3 16.7% · Q4 25.4% · 4Q avg 20.3%
Percentage of long-stay residents who received an antipsychotic medication	23.7%	10.8% 12.9 pts worse	16.7% 7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 26.2% · Q3 25.0% · Q4 29.4% · 4Q avg 23.7% · 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	13.8%	15.4% 1.6 pts better	16.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 17.5% · Q3 18.8% · Q4 11.3% · 4Q avg 13.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.3%	16.1% 1.8 pts better	14.9% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.3% · Q3 19.6% · Q4 17.7% · 4Q avg 14.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.5% 0.1 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	7.6%	15.0% 7.4 pts better	19.8% 12.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.3% · Q3 9.1% · Q4 4.9% · 4Q avg 7.6%
Percentage of long-stay residents with pressure ulcers	5.1%	4.2% 0.9 pts worse	5.1% About the same	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.5% · Q3 8.1% · Q4 6.4% · 4Q avg 5.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.3%	89.7% 7.6 pts better	81.7% 15.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.7% · Q4 90.3% · 4Q avg 97.3%
Percentage of short-stay residents who had an outpatient emergency department visit	16.4%	12.0% 4.4 pts worse	12.0% 4.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 16.7% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	5.4%	1.5% 3.9 pts worse	1.6% 3.8 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 5.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	87.5%	88.0% 0.5 pts worse	79.7% 7.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.2%	25.9% 4.7 pts better	23.9% 2.7 pts better	Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 20.0% · Expected 22.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-09 · Fire 2025-07-09

11 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-05-31 · Fire 2024-05-31

6 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-03-17 · Fire 2023-03-17

10 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-07-09

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2025-07-10

E · Potential for more than minimal harm 2025-07-09

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 2025-07-10

D · Potential for more than minimal harm 2025-07-09

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-07-10

F · Potential for more than minimal harm 2024-05-31

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-31

K321 · Smoke Deficiencies

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 2024-06-25

E · Potential for more than minimal harm 2024-05-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-06-25

E · Potential for more than minimal harm 2024-05-31

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-06-25

F · Potential for more than minimal harm 2023-03-17

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2023-03-20

F · Potential for more than minimal harm 2023-03-17

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-03-17

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-04-04

E · Potential for more than minimal harm 2023-03-17

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-03-20

C · Minimal harm 2023-03-17

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-17

Inspection history

Recent health citations

G · Actual harm 2025-07-09

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-07-15

E · Potential for more than minimal harm 2025-07-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-07-09

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-07-09

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 2025-07-15

D · Potential for more than minimal harm 2025-07-09

F690 · Quality of Life and Care Deficiencies

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 2025-07-15

D · Potential for more than minimal harm 2025-07-09

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 2025-07-15

D · Potential for more than minimal harm 2025-07-09

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-07-09

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-07-09

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 2025-07-15

D · Potential for more than minimal harm 2025-07-09

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2025-07-15

E · Potential for more than minimal harm 2025-04-03

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 2025-04-21

E · Potential for more than minimal harm 2024-05-31

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-06-15

E · Potential for more than minimal harm 2024-05-31

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-06-15

E · Potential for more than minimal harm 2024-05-31

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 2024-06-15

D · Potential for more than minimal harm 2024-05-31

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 2024-06-15

D · Potential for more than minimal harm 2024-04-12

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2024-05-09

D · Potential for more than minimal harm 2024-04-12

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-05-09

G · Actual harm 2023-03-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-03-24

F · Potential for more than minimal harm 2023-03-17

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 2023-03-24

E · Potential for more than minimal harm 2023-03-17

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 2023-03-24

E · Potential for more than minimal harm 2023-03-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-03-24

D · Potential for more than minimal harm 2023-03-17

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2023-03-24

D · Potential for more than minimal harm 2023-03-17

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 2023-03-24

D · Potential for more than minimal harm 2023-03-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-03-24

D · Potential for more than minimal harm 2023-03-17

F690 · Quality of Life and Care Deficiencies

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 2023-03-24

D · Potential for more than minimal harm 2023-03-17

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2023-03-24

D · Potential for more than minimal harm 2023-03-17

F761 · Pharmacy Service Deficiencies

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 2023-03-24

Penalties and ownership