Eagle Pass, TX

Eagle Pass Nursing And Rehabilitation

2-star overall rating with 3-star inspections with $17,419 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

2550 Zacatecas Dr, Eagle Pass, TX

(830) 773-4488

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

114

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Creative Solutions In Healthcare

Operator or chain grouping

Approved since

1996-08-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

149 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 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

0.20

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.08

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.52

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.80

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.28

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.19

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.14

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.21

CMS adjusted RN staffing hours

Adjusted total hours

2.97

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

28%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,010

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

Performance score

28.06

Composite VBP score used to determine payment impact.

Payment multiplier

0.9848

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

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

5.59

Baseline 29.73% · Performance 40.82% · Measure score 5.59 · Achievement 5.59 · Improvement 0

Adjusted total nurse staffing

0.02

Baseline 2.90 hours · Performance 3.05 hours · Measure score 0.02 · Achievement 0 · Improvement 0.02

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.59%	10.72% 0.9 pts worse	No Different than the National Rate · Eligible stays 25 · Observed rate 20% · Lower 95% interval 6.9%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 79
Staff flu vaccination coverage	46.88%	42% 4.9 pts better	Numerator 45 · Denominator 96
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
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	5.9%	3.3% 2.6 pts worse	3.3% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.1% · Q3 3.8% · Q4 5.4% · 4Q avg 5.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.6%	2.7% 1.1 pts better	11.4% 9.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 4.3% · Q4 0.0% · 4Q avg 1.6%
Percentage of long-stay residents who lose too much weight	1.4%	3.3% 1.9 pts better	5.4% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 1.9% · 4Q avg 1.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.6%	18.9% 7.3 pts better	19.6% 8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 10.9% · Q3 11.8% · Q4 9.1% · 4Q avg 11.6%
Percentage of long-stay residents who received an antipsychotic medication	7.6%	10.8% 3.2 pts better	16.7% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 6.0% · Q3 6.5% · Q4 5.8% · 4Q avg 7.6% · 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	9.6%	15.4% 5.8 pts better	16.3% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.2%	16.1% 2.9 pts better	14.9% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 14.3% · Q3 13.3% · Q4 22.9% · 4Q avg 13.2% · 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	1.4%	0.8% 0.6 pts worse	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 2.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	2.3%	15.0% 12.7 pts better	19.8% 17.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 3.8% · Q4 1.7% · 4Q avg 2.3%
Percentage of long-stay residents with pressure ulcers	7.4%	4.2% 3.2 pts worse	5.1% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 7.3% · Q3 11.1% · Q4 5.9% · 4Q avg 7.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.2%	89.7% 6.5 pts better	81.7% 14.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 100.0% · Q3 94.3% · Q4 97.2% · 4Q avg 96.2%
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 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-21 · Fire 2025-05-21

5 health deficiencies

Top issue: Environmental (1 deficiency)

5 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-04-17 · Fire 2024-04-17

13 health deficiencies

Top issue: Administration (3 deficiencies)

3 fire-safety deficiencies

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

Cycle 3 Health 2023-02-23 · Fire 2023-02-23

8 health deficiencies

Top issue: Nursing and Physician Services (2 deficiencies)

4 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-21

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-05-21

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-06-30

D · Potential for more than minimal harm 2025-05-21

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-05-29

D · Potential for more than minimal harm 2025-05-21

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 2025-06-10

C · Minimal harm 2025-05-21

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 2024-04-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-07

E · Potential for more than minimal harm 2024-04-17

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-05-10

C · Minimal harm 2024-04-17

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-04-18

E · Potential for more than minimal harm 2023-02-23

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-03-17

D · Potential for more than minimal harm 2023-02-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-03-27

D · Potential for more than minimal harm 2023-02-23

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-03-17

C · Minimal harm 2023-02-23

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-03-17

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-05-21

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 2025-05-22

E · Potential for more than minimal harm 2025-05-21

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2025-05-22

D · Potential for more than minimal harm 2025-05-21

F942 · Resident Rights Deficiencies

Health

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Corrected 2025-05-22

C · Minimal harm 2025-05-21

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-05-22

J · Immediate jeopardy 2025-04-25

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 2024-09-09

E · Potential for more than minimal harm 2024-04-17

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 2024-04-18

E · Potential for more than minimal harm 2024-04-17

F728 · Nursing and Physician Services Deficiencies

Health

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Corrected 2024-05-01

E · Potential for more than minimal harm 2024-04-17