Cycle 1
Health 2024-10-18 · Fire 2024-10-18
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fredericksburg, TX
Knopp Nursing & Rehab Center Inc
1-star overall rating with 2-star inspections with $32,094 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
202 Billie Dr, Fredericksburg, TX
(830) 997-8840
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-12-11
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
0.25
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.60
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.83
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.47
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
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,749
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.31
Performance 19.44% · Measure score 4.31 · Achievement 4.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.74
Performance 7.02% · Measure score 2.74 · Achievement 2.74 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 41.38% · Performance 82.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.65
Baseline 3.69 hours · Performance 3.26 hours · Measure score 0.65 · Achievement 0.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.23% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 8.45% · Lower 95% interval 6.61% |
| Discharge to community | 54.88% |
50.57%
4.3 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 52.63% · Lower 95% interval 43.6% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.67% |
95.27%
2.4 pts better
|
Numerator 42 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 20 · Denominator 40 |
| Discharge mobility score | 52.5% |
50.94%
1.6 pts better
|
Numerator 21 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 1 · Denominator 43 · Adjusted rate 2.31% |
| Healthcare-associated infections requiring hospitalization | 7.02% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 6.98% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 58 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 20 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.3 · 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 | 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 | 7.2% |
3.3%
3.9 pts worse
|
3.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.4% · Q3 7.4% · Q4 6.7% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
3.3%
3.8 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 0.0% · Q4 8.3% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
18.9%
14.4 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 40.0% · Q3 28.6% · Q4 29.2% · 4Q avg 33.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
10.8%
12.1 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 28.6% · 4Q avg 22.9% · 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 | 26.1% |
15.4%
10.7 pts worse
|
16.3%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
16.1%
3.4 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 4.8% · Q4 29.2% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.5%
0.9 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
0.8%
1.9 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 0.0% · Q4 3.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
15.0%
14.8 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 30.0% · Q3 23.8% · Q4 41.0% · 4Q avg 29.8% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.2%
0.8 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.5% · Q3 2.8% · Q4 2.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
89.7%
4 pts better
|
81.7%
12 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 86.3% · Q3 95.9% · Q4 100.0% · 4Q avg 93.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
12.0%
1.8 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.4% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 3.4% · Q4 4.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.3% |
88.0%
25.7 pts worse
|
79.7%
17.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
25.9%
3.8 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 18.8% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-18 · Fire 2023-09-18
15 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-07-22 · Fire 2022-07-22
3 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-25
E · Potential for more than minimal harm
2024-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-25
E · Potential for more than minimal harm
2024-10-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-25
E · Potential for more than minimal harm
2024-10-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-25
F · Potential for more than minimal harm
2023-09-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-29
F · Potential for more than minimal harm
2023-09-18
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 2023-10-29
F · Potential for more than minimal harm
2023-09-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-29
E · Potential for more than minimal harm
2023-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-29
E · Potential for more than minimal harm
2022-07-22
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 2022-09-02
E · Potential for more than minimal harm
2022-07-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-02
E · Potential for more than minimal harm
2022-07-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-02
Inspection history
Recent health citations
J · Immediate jeopardy
2024-10-18
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 2024-11-19
E · Potential for more than minimal harm
2024-10-18
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 2024-11-19
E · Potential for more than minimal harm
2024-10-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-18
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-18
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 2024-11-19
D · Potential for more than minimal harm
2024-10-18
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 2024-11-19
D · Potential for more than minimal harm
2024-10-18
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 2024-11-19
J · Immediate jeopardy
2024-09-09
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-09-09
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 2024-09-13
D · Potential for more than minimal harm
2024-09-09
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-09
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-09-13
F · Potential for more than minimal harm
2023-09-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-13
F · Potential for more than minimal harm
2023-09-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-11-13
F · Potential for more than minimal harm
2023-09-18
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-11-13
E · Potential for more than minimal harm
2023-09-18
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 2023-11-13
E · Potential for more than minimal harm
2023-09-18
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 2023-11-13
E · Potential for more than minimal harm
2023-09-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-13
E · Potential for more than minimal harm
2023-09-18
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 2023-11-13
E · Potential for more than minimal harm
2023-09-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-09-18
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 2023-11-13
D · Potential for more than minimal harm
2023-09-18
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 2023-11-13
D · Potential for more than minimal harm
2023-09-18
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 2023-11-13
F · Potential for more than minimal harm
2022-07-22
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2022-09-02
F · Potential for more than minimal harm
2022-07-22
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-02
Penalties and ownership
What sits behind the stars
$16,448
2024-10-18
Fine
Fine · fine $16,448
Fine
$0
2024-10-18
Payment Denial
Payment Denial · denial start 2024-11-21 · 4 days
4 day denial
$15,646
2024-09-09
Fine
Fine · fine $15,646
Fine
Ownership
Luchenbach, Jay
5% Or Greater Direct Ownership Interest · Individual
Perry, Jane
5% Or Greater Direct Ownership Interest · Individual
Monkhouse, Mary
5% Or Greater Direct Ownership Interest · Individual
Perry, Chase
5% Or Greater Direct Ownership Interest · Individual
Kothmann, John
Operational/Managerial Control · Individual
Luchenbach, Jay
Corporate Director · Individual
Monkhouse, Mary
Corporate Director · Individual
Perry, Chase
Operational/Managerial Control · Individual
Perry, Chase
Corporate Director · Individual
Perry, Chase
Corporate Officer · Individual
Perry, Jane
Operational/Managerial Control · Individual
Perry, Jane
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Avir At Fredericksburg
Fredericksburg, TX
4-star overall rating with 3-star inspections with $33,145 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Avir at Enchanted Rock
Fredericksburg, TX
1-star overall rating with 2-star inspections with $63,121 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Knopp Healthcare And Rehab Center Inc
Fredericksburg, TX
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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