Cycle 1
Health 2025-03-20 · Fire 2025-03-20
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Austin, TX
Gracy Woods Ii Living Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies
12042 Bittern Hollow, Austin, TX
(512) 730-2100
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
Facility snapshot
Beds
110
Certified beds
Average residents
93
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Caring Healthcare Group
Operator or chain grouping
Approved since
2002-04-26
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
0.26
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.14
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
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,642
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0023
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.42
Baseline 24.39% · Performance 18.56% · Measure score 7.42 · Achievement 6.20 · Improvement 7.42
Healthcare-associated infections
4.29
Baseline 9.35% · Performance 7.27% · Measure score 4.29 · Achievement 1.90 · Improvement 4.29
Total nurse turnover
4.78
Baseline 42.62% · Performance 44.16% · Measure score 4.78 · Achievement 4.78 · Improvement 0
Adjusted total nurse staffing
2.94
Baseline 3.20 hours · Performance 3.91 hours · Measure score 2.94 · Achievement 2.94 · Improvement 2.25
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.91% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 14.93% · Lower 95% interval 8.3% |
| Discharge to community | 41.68% |
50.57%
8.9 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 31.58% · Lower 95% interval 28.12% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.96% |
95.27%
2.7 pts better
|
Numerator 48 · Denominator 49 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 49 |
| Discharge self-care score | 56.82% |
53.69%
3.1 pts better
|
Numerator 25 · Denominator 44 |
| Discharge mobility score | 47.73% |
50.94%
3.2 pts worse
|
Numerator 21 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.27% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 7.89% · Lower 95% interval 3.84% |
| Staff COVID-19 vaccination coverage | 0.9% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 111 |
| Staff flu vaccination coverage | 35.88% |
42%
6.1 pts worse
|
Numerator 47 · Denominator 131 |
| Discharge function score | 56.82% |
56.45%
0.4 pts better
|
Numerator 25 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 10 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.2 · 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 | 97.9% |
97.9%
About the same
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.2% · Q3 4.4% · Q4 1.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
3.3%
2.6 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
18.9%
6.4 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 11.8% · Q3 15.4% · Q4 11.8% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
10.8%
1.4 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 8.6% · Q3 8.5% · Q4 12.9% · 4Q avg 9.4% · 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 | 12.6% |
15.4%
2.8 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 14.6% · Q3 14.4% · Q4 7.1% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
16.1%
0.4 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 11.8% · Q3 15.9% · Q4 15.4% · 4Q avg 16.5% · 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 | 3.8% |
15.0%
11.2 pts better
|
19.8%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.9% · Q3 2.1% · Q4 3.4% · 4Q avg 3.8% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.2%
2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.6% · Q3 1.7% · Q4 2.8% · 4Q avg 2.2% · 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 | 3.6% |
12.0%
8.4 pts better
|
12.0%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.6% · Observed 3.2% · Expected 10.0% · 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% · Q4 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 | 97.1% |
88.0%
9.1 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 0.0% |
25.9%
25.9 pts better
|
23.9%
23.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 17.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-31 · Fire 2024-01-31
4 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-10-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-11
E · Potential for more than minimal harm
2022-10-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-11
D · Potential for more than minimal harm
2022-10-27
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 2023-06-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
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 2025-03-21
E · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-03-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-03-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-21
E · Potential for more than minimal harm
2024-01-31
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 2024-02-01
D · Potential for more than minimal harm
2024-01-31
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 2024-02-01
D · Potential for more than minimal harm
2024-01-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-31
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-05-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-06-05
E · Potential for more than minimal harm
2022-10-27
F584 · Resident Rights Deficiencies
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 2022-11-27
E · Potential for more than minimal harm
2022-10-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-27
E · Potential for more than minimal harm
2022-10-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-10-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-10-27
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-11-27
D · Potential for more than minimal harm
2022-10-27
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 2022-11-27
D · Potential for more than minimal harm
2022-10-27
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 2022-11-27
B · Minimal harm
2022-10-27
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-11-27
Penalties and ownership
What sits behind the stars
Ownership
Byrom, David
Corporate Director · Individual
Byrom, David
W-2 Managing Employee · Individual
Coryell County Memorial Hospital Authority
Operational/Managerial Control · Organization
Gracy Woods Healthcare LLC
Operational/Managerial Control · Organization
Shapiro, Menachem
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Gracy Woods Nursing Center
Austin, TX
0-star overall rating with 0-star inspections with Special Focus status with $171,373 in total fines with 9 recent health deficiencies
#2
Avir at Park Bend
Austin, TX
3-star overall rating with 3-star inspections with $38,155 in total fines with 7 recent health deficiencies
#3
Windsor Nursing And Rehabilitation Center Of Duval
Austin, TX
2-star overall rating with 2-star inspections with $23,341 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out