Cycle 1
Health 2025-03-20 · Fire 2025-03-20
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Hutto, TX
Falcon Ridge Rehabilitation
2-star overall rating with 3-star inspections with $60,135 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
149 Klattenhoff Lane, Hutto, TX
(512) 840-7000
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
140
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
2015-04-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
69 facilities
Chain averages 2 overall / 2 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
0.24
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,363
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.33% · Performance 21.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.49
Baseline 5.95% · Performance 7.39% · Measure score 1.49 · Achievement 1.49 · Improvement 0
Total nurse turnover
0.97
Baseline 57.75% · Performance 59.72% · Measure score 0.97 · Achievement 0.97 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.22 hours · Performance 3.14 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.5% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 5.08% · Lower 95% interval 6.45% |
| Discharge to community | 47.17% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 40% · Lower 95% interval 34.81% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| Discharge self-care score | 56.52% |
53.69%
2.8 pts better
|
Numerator 13 · Denominator 23 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 11 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 3.39% |
| Healthcare-associated infections requiring hospitalization | 7.39% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 160 |
| Staff flu vaccination coverage | 33.98% |
42%
8 pts worse
|
Numerator 35 · Denominator 103 |
| Discharge function score | 56.52% |
56.45%
0.1 pts better
|
Numerator 13 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.3% |
97.1%
22.8 pts worse
|
93.4%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.5% · Q2 74.4% · Q3 77.2% · Q4 73.5% · 4Q avg 74.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.6% |
97.9%
5.3 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.3%
0.9 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.4% · Q3 1.3% · Q4 2.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
2.7%
0.4 pts worse
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.6% · Q3 5.1% · Q4 3.8% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
3.3%
0.8 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.5% · Q4 6.9% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.4% |
18.9%
4.5 pts worse
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 18.8% · Q3 20.9% · Q4 23.3% · 4Q avg 23.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
10.8%
2.1 pts worse
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.5% · Q3 16.9% · Q4 13.3% · 4Q avg 12.9% · 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 | 21.3% |
15.4%
5.9 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
16.1%
1.2 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 19.0% · Q3 10.2% · Q4 20.3% · 4Q avg 17.3% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
15.0%
1.7 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 16.1% · Q3 13.3% · Q4 2.5% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 0.0% · Q3 1.0% · Q4 1.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.4% |
89.7%
6.3 pts worse
|
81.7%
1.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 72.3% · Q2 83.1% · Q3 89.9% · Q4 88.0% · 4Q avg 83.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
12.0%
5.6 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 6.8% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.8% |
88.0%
9.2 pts worse
|
79.7%
0.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.8% |
| 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 25.0% · Expected 28.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
17 health deficiencies
Top issue: Nutrition and Dietary (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-03-20
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 2025-03-28
F · Potential for more than minimal harm
2025-03-20
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-03-20
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 2025-03-28
F · Potential for more than minimal harm
2025-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-03-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-30
E · Potential for more than minimal harm
2024-01-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-27
E · Potential for more than minimal harm
2022-11-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-23
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 2025-06-24
D · Potential for more than minimal harm
2025-03-20
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 2025-03-28
D · Potential for more than minimal harm
2025-03-20
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 2025-03-28
B · Minimal harm
2025-03-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-12-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-12-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-19
E · Potential for more than minimal harm
2024-11-15
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 2024-12-16
E · Potential for more than minimal harm
2024-09-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-08-25
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 2024-08-31
F · Potential for more than minimal harm
2024-01-25
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 2024-02-09
E · Potential for more than minimal harm
2024-01-25
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 2024-02-09
E · Potential for more than minimal harm
2024-01-25
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 2024-02-09
D · Potential for more than minimal harm
2024-01-25
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 2024-02-09
D · Potential for more than minimal harm
2024-01-25
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 2024-02-09
D · Potential for more than minimal harm
2023-12-21
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 2024-01-15
J · Immediate jeopardy
2023-11-01
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 2023-11-02
E · Potential for more than minimal harm
2023-10-09
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 2023-11-06
E · Potential for more than minimal harm
2023-09-25
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 2023-10-16
E · Potential for more than minimal harm
2023-08-15
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 2023-09-01
E · Potential for more than minimal harm
2023-08-08
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 2023-08-29
D · Potential for more than minimal harm
2023-08-08
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-08-29
H · Actual harm
2023-07-27
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-27
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
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 2023-08-25
E · Potential for more than minimal harm
2023-07-05
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 2023-07-12
E · Potential for more than minimal harm
2022-11-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-11-10
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 2022-12-07
E · Potential for more than minimal harm
2022-11-10
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 2022-12-07
D · Potential for more than minimal harm
2022-11-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-07
D · Potential for more than minimal harm
2022-11-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-07
Penalties and ownership
What sits behind the stars
$8,577
2023-09-25
Fine
Fine · fine $8,577
Fine
$51,558
2023-07-05
Fine
Fine · fine $51,558
Fine
Ownership
South Limestone Hospital District
5% Or Greater Direct Ownership Interest · Organization
Calderon, Jorge
Operational/Managerial Control · Individual
Price, Larry
Corporate Officer · Individual
Retama Manor Del Rio LLC
Operational/Managerial Control · Organization
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