Round Rock, TX

Hearthstone Nursing And Rehabilitation

3-star overall rating with 3-star inspections with $152,617 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

401 Oakwood Blvd, Round Rock, TX

(512) 388-7494

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

89

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Caraday Healthcare

Operator or chain grouping

Approved since

1988-09-26

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.45

Registered nurse staffing

LPN hours / resident day

0.58

Licensed practical nurse staffing

Aide hours / resident day

1.91

Nurse aide staffing

Weekend hours

2.51

Weekend nurse staffing

RN turnover

55%

Annual RN turnover

Total nurse turnover

69%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.3
2.1
0.8 pts better
1.9
0.6 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 1.8
2.1
0.3 pts better
1.8
About the same
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 75.0%
97.1%
22.1 pts worse
93.4%
18.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 86.9%
97.9%
11 pts worse
95.5%
8.6 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 6.9%
3.3%
3.6 pts worse
3.3%
3.6 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.4%
2.7%
2.3 pts better
11.4%
11 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 7.2%
3.3%
3.9 pts worse
5.4%
1.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 20.7%
18.9%
1.8 pts worse
19.6%
1.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 13.3%
10.8%
2.5 pts worse
16.7%
3.4 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened 9.0%
15.4%
6.4 pts better
16.3%
7.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 10.2%
16.1%
5.9 pts better
14.9%
4.7 pts better
Long Stay · 2024Q4-2025Q3
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
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
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 23.7%
15.0%
8.7 pts worse
19.8%
3.9 pts worse
Long Stay · 2024Q4-2025Q3
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
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 35.7%
89.7%
54 pts worse
81.7%
46 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 12.4%
12.0%
0.4 pts worse
12.0%
0.4 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 7.0%
1.5%
5.5 pts worse
1.6%
5.4 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 49.5%
88.0%
38.5 pts worse
79.7%
30.2 pts worse
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 35.4%
25.9%
9.5 pts worse
23.9%
11.5 pts worse
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-30 · Fire 2025-01-30

5 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-12-14 · Fire 2023-12-14

8 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-10-20 · Fire 2022-10-20

14 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-01-30

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 2025-03-25

D · Potential for more than minimal harm 2025-01-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-03-25

E · Potential for more than minimal harm 2023-12-14

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2024-02-09

E · Potential for more than minimal harm 2022-10-20

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-06-16

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-14

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 2026-01-26

D · Potential for more than minimal harm 2025-11-19

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 2025-11-26

D · Potential for more than minimal harm 2025-11-19

F646 · Resident Assessment and Care Planning Deficiencies

Health

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Corrected 2025-11-26

D · Potential for more than minimal harm 2025-01-30

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 2025-02-17

D · Potential for more than minimal harm 2025-01-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-17

G · Actual harm 2024-12-19

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 2024-12-03

D · Potential for more than minimal harm 2024-12-19

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 2025-01-14

D · Potential for more than minimal harm 2024-04-03

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 2024-04-25

E · Potential for more than minimal harm 2024-02-13

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-03-11

D · Potential for more than minimal harm 2024-02-13

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2024-03-11

D · Potential for more than minimal harm 2024-02-13

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-03-11

E · Potential for more than minimal harm 2023-12-14

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 2024-01-20

E · Potential for more than minimal harm 2023-12-14

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-01-20

E · Potential for more than minimal harm 2023-12-14

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-01-20

E · Potential for more than minimal harm 2023-12-14

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-01-20

E · Potential for more than minimal harm 2023-12-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-20

K · Immediate jeopardy 2023-12-02

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-11-16

K · Immediate jeopardy 2023-12-02

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 2023-11-16

K · Immediate jeopardy 2023-12-02

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-11-16

E · Potential for more than minimal harm 2023-12-02

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 2023-12-08

J · Immediate jeopardy 2023-07-31

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 2023-08-25

J · Immediate jeopardy 2023-07-31

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 2023-08-25

F · Potential for more than minimal harm 2022-10-20

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2022-12-05

F · Potential for more than minimal harm 2022-10-20

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2022-12-05

D · Potential for more than minimal harm 2022-10-20

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 2022-11-18

D · Potential for more than minimal harm 2022-10-20

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 2022-11-18

D · Potential for more than minimal harm 2022-10-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-12-05

Penalties and ownership

What sits behind the stars

$10,033 2024-12-19

Fine

Fine · fine $10,033

Fine

$15,593 2023-12-02

Fine

Fine · fine $15,593

Fine

$126,991 2023-07-31

Fine

Fine · fine $126,991

Fine

Ownership

Stratford Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 28 facilities 2020-06-01
Caraday Hearthstone LLC

Operational/Managerial Control · Organization

0% 1 facilities 2020-06-01
Chumley, Richard

Corporate Officer · Individual

0% 30 facilities 2020-06-01
Granite Hearthstone Health Center, LLC

5% Or Greater Mortgage Interest · Organization

0% 1 facilities 2020-06-01
Moore, Gregory

Operational/Managerial Control · Individual

0% 14 facilities 2020-06-01

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Staffing
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Staffing
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Fines
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#3

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5-star overall rating with 4-star inspections with 10 recent health deficiencies

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Health
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Staffing
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Fines
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