Navasota, TX

Golden Creek Healthcare And Rehabilitation Center

4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

2100 Dover Crossing Lane, Navasota, TX

(936) 825-4043

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

125

Certified beds

Average residents

88

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Nexion Health

Operator or chain grouping

Approved since

2006-04-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

52 facilities

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

0.34

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.77

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.18

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.29

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.10

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.89

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

0.06

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.34

CMS adjusted RN staffing hours

Adjusted total hours

3.35

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,554

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

Performance score

29.44

Composite VBP score used to determine payment impact.

Payment multiplier

0.9855

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.36

Baseline 21.69% · Performance 20.82% · Measure score 1.36 · Achievement 1.31 · Improvement 1.36

Healthcare-associated infections

5.11

Baseline 8.43% · Performance 6.50% · Measure score 5.11 · Achievement 4.46 · Improvement 5.11

Total nurse turnover

5.31

Baseline 59.74% · Performance 41.98% · Measure score 5.31 · Achievement 5.31 · Improvement 4.59

Adjusted total nurse staffing

0

Baseline 3.26 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.88%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 69 · Observed rate 13.04% · Lower 95% interval 7.46%
Discharge to community	54.59%	50.57% 4 pts better	No Different than the National Rate · Eligible stays 47 · Observed rate 44.68% · Lower 95% interval 41.81%
Medicare spending per beneficiary	1.06	1.02 About the same
Drug regimen review with follow-up	95.83%	95.27% 0.6 pts better	Numerator 46 · Denominator 48
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 48
Discharge self-care score	48.48%	53.69% 5.2 pts worse	Numerator 16 · Denominator 33
Discharge mobility score	48.48%	50.94% 2.5 pts worse	Numerator 16 · Denominator 33
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 48 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.5%	7.12% 0.6 pts better	No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 3.1%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 91
Staff flu vaccination coverage	18.45%	42% 23.6 pts worse	Numerator 19 · Denominator 103
Discharge function score	48.48%	56.45% 8 pts worse	Numerator 16 · Denominator 33
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 27 · Denominator 27
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · 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	2.6	2.1 0.5 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.2 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	2.1 0.8 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · 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	98.9%	97.9% 1 pts better	95.5% 3.4 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9%
Percentage of long-stay residents experiencing one or more falls with major injury	6.3%	3.3% 3 pts worse	3.3% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.7% · Q3 7.0% · Q4 9.8% · 4Q avg 6.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.7%	2.7% 2 pts better	11.4% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 0.7%
Percentage of long-stay residents who lose too much weight	3.8%	3.3% 0.5 pts worse	5.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 5.2% · Q4 1.4% · 4Q avg 3.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.1%	18.9% 6.8 pts better	19.6% 7.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 12.2% · Q3 10.1% · Q4 11.1% · 4Q avg 12.1%
Percentage of long-stay residents who received an antipsychotic medication	7.8%	10.8% 3 pts better	16.7% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.7% · Q3 8.2% · Q4 8.5% · 4Q avg 7.8% · 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	10.8%	15.4% 4.6 pts better	16.3% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.8% · Q3 11.4% · Q4 13.5% · 4Q avg 10.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.7%	16.1% 2.4 pts better	14.9% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 9.0% · Q3 20.3% · Q4 17.7% · 4Q avg 13.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.5% 0.2 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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	12.8%	15.0% 2.2 pts better	19.8% 7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 14.7% · Q3 8.7% · Q4 14.6% · 4Q avg 12.8%
Percentage of long-stay residents with pressure ulcers	2.6%	4.2% 1.6 pts better	5.1% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.0% · Q3 4.2% · Q4 1.6% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.2%	89.7% 8.5 pts better	81.7% 16.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.3% · Q3 98.1% · Q4 98.2% · 4Q avg 98.2%
Percentage of short-stay residents who had an outpatient emergency department visit	8.8%	12.0% 3.2 pts better	12.0% 3.2 pts better	Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 10.5% · Expected 13.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.1%	1.5% 1.6 pts worse	1.6% 1.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.2%	88.0% 5.2 pts better	79.7% 13.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.9%	25.9% 2 pts worse	23.9% 4 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 31.6% · Expected 27.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-30 · Fire 2025-04-30

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-04-11 · Fire 2024-04-11

6 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-03-16 · Fire 2023-03-16

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-03

F · Potential for more than minimal harm 2025-04-30

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-06-03

F · Potential for more than minimal harm 2024-04-11

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-02-07

F · Potential for more than minimal harm 2024-04-11

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-02-07

E · Potential for more than minimal harm 2024-04-11

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-02-07

E · Potential for more than minimal harm 2024-04-11

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-02-07

E · Potential for more than minimal harm 2024-04-11

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-02-07

E · Potential for more than minimal harm 2024-04-11

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2025-02-07

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-06

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 2025-08-08

D · Potential for more than minimal harm 2025-08-06

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 2025-08-08

D · Potential for more than minimal harm 2025-08-06

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-08-08

D · Potential for more than minimal harm 2025-07-08

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 2025-07-10

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 2025-05-02

F · Potential for more than minimal harm 2024-04-11

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 2024-04-15

D · Potential for more than minimal harm 2024-04-11

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-04-11

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-04-11

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-04-11

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-04-11

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 2024-04-15

E · Potential for more than minimal harm 2024-01-24

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 2024-01-29

F · Potential for more than minimal harm 2023-03-16

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 2023-03-22

D · Potential for more than minimal harm 2023-03-16

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 2023-03-22

D · Potential for more than minimal harm 2023-03-16

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 2023-03-22

D · Potential for more than minimal harm 2023-03-16

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 2023-03-22

Penalties and ownership

What sits behind the stars

Ownership

Memorial Medical Center

5% Or Greater Direct Ownership Interest · Organization

100% 3 facilities 2017-04-01

Fallon, John