Cycle 1
Health 2024-10-16 · Fire 2024-10-16
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Wills Point, TX
Crestwood Health And Rehabilitation Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1448 Houston St, Wills Point, TX
(903) 873-5400
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1996-05-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.35
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,456
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.13% · Performance 21.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.87% · Performance 10.13% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 72.92% · Performance 75.68% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2
Baseline 3.14 hours · Performance 3.65 hours · Measure score 2 · Achievement 2 · Improvement 1.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 9.46% · Lower 95% interval 6.57% |
| Discharge to community | 45.18% |
50.57%
5.4 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 36.36% · Lower 95% interval 33.1% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.48% |
95.27%
1.8 pts worse
|
Numerator 43 · Denominator 46 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 46 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 9 · Denominator 27 |
| Discharge mobility score | 62.96% |
50.94%
12 pts better
|
Numerator 17 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 2 · Denominator 46 · Adjusted rate 4.78% |
| Healthcare-associated infections requiring hospitalization | 10.13% |
7.12%
3 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 20.45% · Lower 95% interval 6.14% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | 32.12% |
42%
9.9 pts worse
|
Numerator 53 · Denominator 165 |
| Discharge function score | 59.26% |
56.45%
2.8 pts better
|
Numerator 16 · Denominator 27 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
97.1%
1.1 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 96.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.2% |
97.9%
4.7 pts worse
|
95.5%
2.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.6% · Q3 3.4% · Q4 1.8% · 4Q avg 2.7% · 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 2.3% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
3.3%
0.2 pts worse
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.0% · Q3 1.9% · Q4 4.2% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
18.9%
6.6 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 29.4% · Q3 19.2% · Q4 18.4% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
10.8%
4.2 pts worse
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 19.1% · Q3 15.2% · Q4 10.3% · 4Q avg 15.0% · 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 | 40.9% |
15.4%
25.5 pts worse
|
16.3%
24.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 38.2% · Q3 35.4% · Q4 51.1% · 4Q avg 40.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.3% |
16.1%
21.2 pts worse
|
14.9%
22.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 35.3% · Q3 25.6% · Q4 41.3% · 4Q avg 37.3% · 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 | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
15.0%
11.4 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.6% · Q2 25.3% · Q3 17.4% · Q4 22.1% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.2%
0.6 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.3% · Q3 4.7% · Q4 3.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
89.7%
5.4 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 91.4% · Q3 98.2% · Q4 98.6% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
12.0%
4.9 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 8.1% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 7.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
88.0%
0.1 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
25.9%
2.9 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 27.0% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-23 · Fire 2023-08-23
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-07-12 · Fire 2022-07-12
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-10-16
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-10-30
C · Minimal harm
2024-10-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
C · Minimal harm
2023-08-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2022-07-12
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-07-22
E · Potential for more than minimal harm
2022-07-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-11
C · Minimal harm
2022-07-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-16
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-08-30
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 2024-08-31
E · Potential for more than minimal harm
2023-08-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-24
E · Potential for more than minimal harm
2023-08-23
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 2023-08-24
D · Potential for more than minimal harm
2023-08-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-24
C · Minimal harm
2023-08-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-24
B · Minimal harm
2023-08-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-06-21
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 2023-07-21
D · Potential for more than minimal harm
2022-07-12
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 2022-08-04
C · Minimal harm
2022-07-12
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-08-04
Penalties and ownership
What sits behind the stars
Ownership
Appaloosa Healthcare, Inc.
Operational/Managerial Control · Organization
Burnam, Soon
Corporate Officer · Individual
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Jensen, Kevin
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Rojas, Jorge
Operational/Managerial Control · Individual
Taylor, Stephen
Corporate Officer · Individual
The Ensign Group Inc
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
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3-star overall rating with 3-star inspections with $67,903 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Avir at Grand Saline
Grand Saline, TX
3-star overall rating with 3-star inspections with $12,740 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Countryview Nursing & Rehabilitation
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1-star overall rating with 1-star inspections with abuse icon flag with $94,108 in total fines with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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