7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Franklin, TX
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
700 Hearne St, Franklin, TX
(979) 828-5152
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
90
Certified beds
Average residents
53
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2001-04-18
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
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.36
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.94
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.40
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
4,223
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9937
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
8.17
Baseline 32.43% · Performance 30.30% · Measure score 8.17 · Achievement 8.17 · Improvement 2.31
Adjusted total nurse staffing
0
Baseline 3.47 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.22% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 13.33% · Lower 95% interval 6.99% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.7 |
1.02
0.7 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 20 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 1 · Denominator 20 · Adjusted rate 3.88% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · 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 101 |
| Staff flu vaccination coverage | 18.97% |
42%
23 pts worse
|
Numerator 22 · Denominator 116 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · 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 14 · Too few residents or stays to report publicly. |
Quality measures
| 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 2.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| 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 | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.8% · Q3 2.0% · Q4 0.0% · 4Q avg 1.9% · 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 | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 10.2% |
18.9%
8.7 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.6% · Q3 10.6% · Q4 11.9% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
10.8%
10.8 pts better
|
16.7%
16.7 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 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 | 9.2% |
15.4%
6.2 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 10.8% · Q3 0.0% · Q4 7.6% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
16.1%
5.1 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 12.8% · Q3 2.2% · Q4 10.0% · 4Q avg 11.0% · 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 | 1.0% |
0.8%
0.2 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.5% |
15.0%
1.5 pts worse
|
19.8%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 22.9% · Q3 9.1% · Q4 12.0% · 4Q avg 16.5% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.2%
2.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 0.0% · Q4 3.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
12.0%
2 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.7% · Expected 10.8% · Used in QM five-star |
| 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 · Q2 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% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.3% |
25.9%
13.6 pts better
|
23.9%
11.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 12.9% · Expected 25.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Have proper medical gas storage and administration areas.
Not marked corrected
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-09
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-16
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-26
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-26
Inspection history
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-12-05
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-09-12
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-12
Health
Provide activities to meet all resident's needs.
Corrected 2025-09-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-12
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 2025-04-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-16
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 2024-08-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-12-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-17
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-07-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-17
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-17
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-17
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
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