Cycle 1
Health 2025-07-30 · Fire 2025-07-30
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Garrison, TX
Garrison Nursing Home & Rehabilitation Center
3-star overall rating with 3-star inspections with $52,951 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
333 North Fm 95, Garrison, TX
(936) 347-2234
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caring Healthcare Group
Operator or chain grouping
Approved since
2008-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 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
0.29
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,084
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.09% · Performance 24.58% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.39
Baseline 5.56% · Performance 6.82% · Measure score 3.39 · Achievement 3.39 · Improvement 0
Total nurse turnover
5.63
Baseline 49.43% · Performance 40.66% · Measure score 5.63 · Achievement 5.63 · Improvement 3.07
Adjusted total nurse staffing
4.60
Baseline 4.03 hours · Performance 4.39 hours · Measure score 4.60 · Achievement 4.60 · Improvement 1.52
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 10.83% · Lower 95% interval 7.68% |
| Discharge to community | 58.98% |
50.57%
8.4 pts better
|
No Different than the National Rate · Eligible stays 114 · Observed rate 61.4% · Lower 95% interval 50.36% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 5.1% |
95.27%
90.2 pts worse
|
Numerator 5 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 28 · Denominator 44 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 20 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 98 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 5.83% · Lower 95% interval 4.12% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 131 |
| Staff flu vaccination coverage | 18% |
42%
24 pts worse
|
Numerator 36 · Denominator 200 |
| Discharge function score | 59.09% |
56.45%
2.6 pts better
|
Numerator 26 · Denominator 44 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 91.38% |
25.2%
66.2 pts better
|
Numerator 53 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.2 |
2.1
2.1 pts worse
|
1.9
2.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 2.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.3 |
2.1
3.2 pts worse
|
1.8
3.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.3 · Observed 4.1 · Expected 1.3 · 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 | 1.8% |
3.3%
1.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 2.9% · Q4 1.3% · 4Q avg 1.8% · 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 | 2.8% |
3.3%
0.5 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 1.9% · Q4 5.2% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
18.9%
6.5 pts better
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 13.8% · Q3 14.8% · Q4 11.5% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
10.8%
2.2 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.7% · Q3 7.3% · Q4 11.6% · 4Q avg 8.6% · 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 | 3.2% |
15.4%
12.2 pts better
|
16.3%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.3% · Q3 3.2% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.1%
6.8 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 12.7% · Q3 1.9% · Q4 15.5% · 4Q avg 9.3% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 with new or worsened bowel or bladder incontinence | 2.7% |
15.0%
12.3 pts better
|
19.8%
17.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 1.4% · Q4 5.0% · 4Q avg 2.7% |
| 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 1.6% · Q2 2.8% · Q3 3.0% · Q4 2.4% · 4Q avg 2.5% · 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 | 26.3% |
12.0%
14.3 pts worse
|
12.0%
14.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 27.5% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.8% · 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 | 34.4% |
25.9%
8.5 pts worse
|
23.9%
10.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.4% · Observed 34.1% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-26 · Fire 2024-06-26
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-07-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-30
F · Potential for more than minimal harm
2024-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-06-26
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-07-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-30
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 2025-07-31
E · Potential for more than minimal harm
2025-07-30
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 2025-07-31
D · Potential for more than minimal harm
2025-07-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-06-26
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 2024-06-27
C · Minimal harm
2024-06-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-06-27
K · Immediate jeopardy
2024-02-08
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 2024-02-09
J · Immediate jeopardy
2024-02-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-12
E · Potential for more than minimal harm
2024-02-08
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 2024-02-09
D · Potential for more than minimal harm
2024-02-08
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2024-02-09
E · Potential for more than minimal harm
2023-05-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-05-10
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 2023-05-12
D · Potential for more than minimal harm
2023-05-10
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 2023-05-12
Penalties and ownership
What sits behind the stars
$28,129
2024-08-22
Fine
Fine · fine $28,129
Fine
$8,021
2024-02-08
Fine
Fine · fine $8,021
Fine
$16,801
2024-02-08
Fine
Fine · fine $16,801
Fine
Ownership
Havins, Joshua
W-2 Managing Employee · Individual
Murrell, Edward
Corporate Officer · Individual
Shapiro, Menachem
Operational/Managerial Control · Individual
Winnie-Stowell Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Stallings Court Nursing And Rehabilitation
Nacogdoches, TX
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Willowbrook Nursing Center
Nacogdoches, TX
2-star overall rating with 2-star inspections with $153,439 in total fines with 8 recent health deficiencies
#3
Westward Trails Nursing And Rehabilitation
Nacogdoches, TX
3-star overall rating with 3-star inspections with $33,060 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out