Falfurrias, TX

Gulf Shores Rehabilitation & Healthcare Center

4-star overall rating with 4-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1301 S Terrell St, Falfurrias, TX

(361) 325-3658

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 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

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Nexion Health

Operator or chain grouping

Approved since

1996-07-31

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

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

1.19

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.76

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.36

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.61

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.15

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.56

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.35

CMS adjusted total nurse staffing hours

Case-mix index

1.37

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

41%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,688

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

Performance score

48.26

Composite VBP score used to determine payment impact.

Payment multiplier

1.0020

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.17

Performance 19.03% · Measure score 5.17 · Achievement 5.17 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

4.67

Performance 6.44% · Measure score 4.67 · Achievement 4.67 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

9.46

Baseline 15.15% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 0

Adjusted total nurse staffing

Baseline 3.39 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.41%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 7.04%
Discharge to community	53.31%	50.57% 2.7 pts better	No Different than the National Rate · Eligible stays 25 · Observed rate 48% · Lower 95% interval 37.6%
Medicare spending per beneficiary	0.95	1.02 0.1 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	6.44%	7.12% 0.7 pts better	No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 3.21%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 60
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 60
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
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	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 6 · 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	2.4	2.1 0.3 pts worse	1.9 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.6 · 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 1.1 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	97.1% 2.3 pts better	93.4% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.7% · 4Q avg 99.4%
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	2.8%	3.3% 0.5 pts better	3.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 4.5% · Q4 4.5% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.2%	2.7% 1.5 pts better	11.4% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 1.2%
Percentage of long-stay residents who lose too much weight	2.6%	3.3% 0.7 pts better	5.4% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 5.1% · Q4 2.7% · 4Q avg 2.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.4%	18.9% 2.5 pts worse	19.6% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.0% · Q3 20.0% · Q4 25.6% · 4Q avg 21.4%
Percentage of long-stay residents who received an antipsychotic medication	6.5%	10.8% 4.3 pts better	16.7% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.4% · Q3 6.1% · Q4 3.2% · 4Q avg 6.5% · 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	21.6%	15.4% 6.2 pts worse	16.3% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	24.8%	16.1% 8.7 pts worse	14.9% 9.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 23.3% · Q3 23.5% · Q4 21.9% · 4Q avg 24.8% · 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	15.7%	15.0% 0.7 pts worse	19.8% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 18.5% · Q3 18.6% · Q4 14.4% · 4Q avg 15.7%
Percentage of long-stay residents with pressure ulcers	0.0%	4.2% 4.2 pts better	5.1% 5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine	84.1%	89.7% 5.6 pts worse	81.7% 2.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 92.9% · Q3 78.4% · Q4 74.5% · 4Q avg 84.1%
Percentage of short-stay residents who had an outpatient emergency department visit	0.0%	12.0% 12 pts better	12.0% 12 pts better	Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 14.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.7%	1.5% 0.2 pts worse	1.6% 0.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 3.1% · Q4 2.7% · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.5%	88.0% 5.5 pts better	79.7% 13.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	15.2%	25.9% 10.7 pts better	23.9% 8.7 pts better	Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 16.0% · Expected 25.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-04 · Fire 2024-12-04

12 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-09-14 · Fire 2023-09-14

4 health deficiencies

Top issue: Administration (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-06-30 · Fire 2022-06-30

6 health deficiencies

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

7 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-31

F · Potential for more than minimal harm 2024-12-04

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-01-31

C · Minimal harm 2024-12-04

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-01-31

D · Potential for more than minimal harm 2023-09-14

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-10-05

C · Minimal harm 2023-09-14

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-10-05

F · Potential for more than minimal harm 2022-06-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-08-20

F · Potential for more than minimal harm 2022-06-30

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2022-08-20

E · Potential for more than minimal harm 2022-06-30

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-08-20

E · Potential for more than minimal harm 2022-06-30

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 2022-08-20

E · Potential for more than minimal harm 2022-06-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-08-20

E · Potential for more than minimal harm 2022-06-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-08-20

C · Minimal harm 2022-06-30

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-08-20

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-16

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-08-25

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

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 2025-07-29

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

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 2025-07-29

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

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-29

C · Minimal harm 2025-03-22

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-04-07

E · Potential for more than minimal harm 2024-12-04

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 2024-12-23