Cycle 1
Health 2025-04-30 · Fire 2025-04-30
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Georgetown, TX
Georgetown Nursing and Transitional Care
2-star overall rating with 2-star inspections with $8,281 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4011 Williams Dr, Georgetown, TX
(512) 868-2700
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
142
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-04-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.42
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
2.44
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.34
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
0.45
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,139
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.52
Composite VBP score used to determine payment impact.
Payment multiplier
1.0147
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.01
Baseline 18.18% · Performance 19.57% · Measure score 4.01 · Achievement 4.01 · Improvement 0
Healthcare-associated infections
9.27
Baseline 6.33% · Performance 5.07% · Measure score 9.27 · Achievement 9.27 · Improvement 8.98
Total nurse turnover
7.53
Baseline 50.00% · Performance 32.91% · Measure score 7.53 · Achievement 7.53 · Improvement 6.30
Adjusted total nurse staffing
3
Baseline 4.12 hours · Performance 3.93 hours · Measure score 3 · Achievement 3 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 263 · Observed rate 8.75% · Lower 95% interval 7.3% |
| Discharge to community | 53.36% |
50.57%
2.8 pts better
|
No Different than the National Rate · Eligible stays 231 · Observed rate 51.08% · Lower 95% interval 46.19% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 136 · Denominator 136 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 136 |
| Discharge self-care score | 47.11% |
53.69%
6.6 pts worse
|
Numerator 57 · Denominator 121 |
| Discharge mobility score | 49.59% |
50.94%
1.3 pts worse
|
Numerator 60 · Denominator 121 |
| Pressure ulcers or injuries, new or worsened | 4.41% |
2.29%
2.1 pts worse
|
Numerator 6 · Denominator 136 · Adjusted rate 3.86% |
| Healthcare-associated infections requiring hospitalization | 5.07% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 137 · Observed rate 1.46% · Lower 95% interval 2.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 165 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50.41% |
56.45%
6 pts worse
|
Numerator 61 · Denominator 121 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 96 · Denominator 96 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 61 |
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 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.1%
2.5 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.2% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
97.9%
0.3 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| 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 3.8% · Q3 1.9% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
2.7%
1.2 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 4.4% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
3.3%
0.8 pts worse
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 4.4% · Q3 6.2% · Q4 4.1% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
18.9%
9.4 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 10.6% · Q3 6.2% · Q4 10.0% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
10.8%
5 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 15.0% · Q3 17.5% · Q4 15.0% · 4Q avg 15.8% · 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 | 37.6% |
15.4%
22.2 pts worse
|
16.3%
21.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.1% |
16.1%
13 pts worse
|
14.9%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 28.6% · Q3 37.2% · Q4 39.5% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.5%
1.1 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.3% · Q3 2.7% · Q4 1.5% · 4Q avg 1.6% · 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 0.0% · Q3 3.7% · 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 | 17.3% |
15.0%
2.3 pts worse
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 16.8% · Q3 25.9% · Q4 23.8% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
4.2%
2.9 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 7.1% · Q3 6.0% · Q4 4.6% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
89.7%
0.7 pts better
|
81.7%
8.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 94.3% · Q3 89.0% · Q4 86.9% · 4Q avg 90.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
12.0%
1.6 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 9.6% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
88.0%
2 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
25.9%
9.3 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 13.8% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
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
2025-04-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-21
F · Potential for more than minimal harm
2024-02-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-02-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-02-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-15
D · Potential for more than minimal harm
2024-02-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-02-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-30
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 2025-05-30
E · Potential for more than minimal harm
2025-04-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-30
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 2025-05-27
E · Potential for more than minimal harm
2025-04-30
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 2025-05-01
E · Potential for more than minimal harm
2025-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-30
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-04-30
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-30
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 2025-05-23
J · Immediate jeopardy
2025-03-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-23
D · Potential for more than minimal harm
2025-03-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-03
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 2025-02-07
D · Potential for more than minimal harm
2025-03-03
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-02-07
F · Potential for more than minimal harm
2024-02-29
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 2024-03-01
E · Potential for more than minimal harm
2024-02-29
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-04-21
D · Potential for more than minimal harm
2024-02-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-01
E · Potential for more than minimal harm
2022-12-09
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 2023-01-13
Penalties and ownership
What sits behind the stars
$8,281
2025-03-17
Fine
Fine · fine $8,281
Fine
Ownership
Chaney, Dena
Operational/Managerial Control · Individual
Donohue, Lorena
Operational/Managerial Control · Individual
Price, Larry
Corporate Director · Individual
South Limestone Hospital District
Operational/Managerial Control · Organization
Strong, Tyler
Operational/Managerial Control · Individual
Nearby options
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#2
Bel Air At Teravista
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4-star overall rating with 3-star inspections with $19,188 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
San Gabriel Rehabilitation and Care Center
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1-star overall rating with 1-star inspections with abuse icon flag with $8,281 in total fines with 13 recent health deficiencies
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