Cycle 1
Health 2024-11-27 · Fire 2024-11-27
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gatesville, TX
Coryell Health Rehabliving At The Meadows
3-star overall rating with 4-star inspections with 6 recent health deficiencies
110 Chicktown Rd, Gatesville, TX
(254) 404-2500
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
99
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-09-20
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
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
9,549
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.91
Baseline 20.64% · Performance 20.08% · Measure score 2.91 · Achievement 2.91 · Improvement 1.04
Healthcare-associated infections
4
Baseline 6.85% · Performance 6.64% · Measure score 4 · Achievement 4 · Improvement 0.62
Total nurse turnover
0
Baseline 52.17% · Performance 66.10% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.42
Baseline 4.07 hours · Performance 3.77 hours · Measure score 2.42 · Achievement 2.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.17% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 174 · Observed rate 10.92% · Lower 95% interval 8.55% |
| Discharge to community | 55.66% |
50.57%
5.1 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 59.73% · Lower 95% interval 48.4% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 92 · Denominator 92 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 2 · Denominator 92 |
| Discharge self-care score | 82.28% |
53.69%
28.6 pts better
|
Numerator 65 · Denominator 79 |
| Discharge mobility score | 87.34% |
50.94%
36.4 pts better
|
Numerator 69 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 92 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 3.96% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 116 |
| Staff flu vaccination coverage | 88.35% |
42%
46.3 pts better
|
Numerator 91 · Denominator 103 |
| Discharge function score | 88.61% |
56.45%
32.2 pts better
|
Numerator 70 · Denominator 79 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 68.29% |
25.2%
43.1 pts better
|
Numerator 28 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.1
1.9 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
97.1%
0.5 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.4% · Q4 92.8% · 4Q avg 97.6% |
| 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 | 5.2% |
3.3%
1.9 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.8% · Q3 6.5% · Q4 7.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 2.5% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
3.3%
1.8 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 1.8% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
18.9%
5.9 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 28.2% · Q3 24.1% · Q4 22.7% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
10.8%
2.3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.8% · Q3 7.8% · Q4 12.3% · 4Q avg 8.5% · 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 | 36.7% |
15.4%
21.3 pts worse
|
16.3%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 39.2% · Q3 36.9% · Q4 40.7% · 4Q avg 36.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.5% |
16.1%
13.4 pts worse
|
14.9%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 23.5% · Q3 25.9% · Q4 43.9% · 4Q avg 29.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.5%
1.2 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.5% · Q3 1.2% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
0.8%
1.7 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.3% · Q4 7.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
15.0%
0.4 pts worse
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 5.4% · Q3 18.3% · Q4 24.7% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.2%
1.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.5% · Q3 1.4% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.0% |
89.7%
4.7 pts worse
|
81.7%
3.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 96.2% · Q3 86.5% · Q4 66.7% · 4Q avg 85.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.7% |
12.0%
9.7 pts worse
|
12.0%
9.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 22.7% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 1.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
88.0%
5.8 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
25.9%
About the same
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 22.7% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-22 · Fire 2022-07-22
8 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-09-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-09-09
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 2025-10-03
F · Potential for more than minimal harm
2024-11-27
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 2024-12-17
E · Potential for more than minimal harm
2024-11-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-05-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-30
E · Potential for more than minimal harm
2023-09-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-28
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 2023-10-18
D · Potential for more than minimal harm
2023-09-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-28
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-03-22
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-03-31
E · Potential for more than minimal harm
2022-07-22
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 2022-08-30
D · Potential for more than minimal harm
2022-07-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-22
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-22
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-22
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-07-22
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 2022-08-30
Penalties and ownership
What sits behind the stars
Ownership
Byrom, David
Operational/Managerial Control · Individual
Byrom, David
Corporate Officer · Individual
Coryell County Memorial Hospital Authority
Operational/Managerial Control · Organization
Cox, Kara
Corporate Director · Individual
May, Maranda
Corporate Director · Individual
Wuenschel, Diedra
Corporate Director · Individual
Nearby options
Other facilities in reach
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Hillside Medical Lodge
Gatesville, TX
2-star overall rating with 3-star inspections with 8 recent health deficiencies
#2
Coral Rehabilitation and Nursing of McGregor
Mc Gregor, TX
1-star overall rating with 1-star inspections with $49,443 in total fines with 8 recent health deficiencies
#3
Killeen Nursing & Rehabilitation
Killeen, TX
1-star overall rating with 1-star inspections with abuse icon flag with $125,321 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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