Cycle 1
Health 2025-12-10 · Fire 2025-12-10
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Eagle Pass, TX
La Hacienda De Paz Rehabilitation and Care Center
2-star overall rating with 2-star inspections with abuse icon flag with $21,645 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3333 Bob Rogers Dr, Eagle Pass, TX
(830) 213-8138
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
96
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2017-04-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,569
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.90
Baseline 18.79% · Performance 20.09% · Measure score 2.90 · Achievement 2.90 · Improvement 0
Healthcare-associated infections
0
Baseline 5.98% · Performance 8.68% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.41
Baseline 45.45% · Performance 37.50% · Measure score 6.41 · Achievement 6.41 · Improvement 3.36
Adjusted total nurse staffing
0
Baseline 2.73 hours · Performance 2.60 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.94% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 12.5% · Lower 95% interval 7.75% |
| Discharge to community | 48.62% |
50.57%
2 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 38.89% · Lower 95% interval 36.29% |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 89.66% |
95.27%
5.6 pts worse
|
Numerator 26 · Denominator 29 |
| Falls with major injury | 3.45% |
0.77%
2.7 pts worse
|
Numerator 1 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 1 · Denominator 29 · Adjusted rate 1.99% |
| Healthcare-associated infections requiring hospitalization | 8.68% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 17.65% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | 42.77% |
42%
0.8 pts better
|
Numerator 68 · Denominator 159 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.17% |
25.2%
21 pts worse
|
Numerator 1 · Denominator 24 |
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 2.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.1
1.6 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.6 · Expected 1.6 · 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 | 4.1% |
3.3%
0.8 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.9% · Q3 6.2% · Q4 2.3% · 4Q avg 4.1% · 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 1.5% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
3.3%
0.6 pts worse
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.2% · Q3 2.5% · Q4 3.5% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.1% |
18.9%
12.8 pts better
|
19.6%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.1% · Q3 7.5% · Q4 7.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
10.8%
2.9 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 6.3% · Q3 8.2% · Q4 6.5% · 4Q avg 7.9% · 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 | 10.9% |
15.4%
4.5 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 0.0% · Q3 15.4% · Q4 12.7% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
16.1%
2.9 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 8.1% · Q3 9.6% · Q4 32.1% · 4Q avg 19.0% · 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 | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.6% |
15.0%
2.4 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 5.3% · Q3 18.6% · Q4 13.4% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
4.2%
2.3 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.2% · Q3 4.8% · Q4 2.9% · 4Q avg 6.5% · 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 | 15.4% |
12.0%
3.4 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 17.1% · Expected 12.4% · 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 · 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 who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
25.9%
0.5 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 34.3% · Expected 30.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-23 · Fire 2024-08-23
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-07-12 · Fire 2023-07-12
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-13
E · Potential for more than minimal harm
2025-12-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-14
D · Potential for more than minimal harm
2024-08-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-10
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-12-28
E · Potential for more than minimal harm
2025-12-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-14
D · Potential for more than minimal harm
2025-12-10
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 2025-12-16
D · Potential for more than minimal harm
2025-12-10
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 2025-12-15
D · Potential for more than minimal harm
2025-12-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-12-10
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 2025-12-26
D · Potential for more than minimal harm
2025-12-10
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 2025-12-18
D · Potential for more than minimal harm
2025-12-10
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 2025-12-18
D · Potential for more than minimal harm
2025-12-10
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-12-13
D · Potential for more than minimal harm
2025-12-10
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 2025-12-16
D · Potential for more than minimal harm
2025-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-19
J · Immediate jeopardy
2025-05-15
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 2025-03-29
D · Potential for more than minimal harm
2025-05-15
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 2025-06-13
D · Potential for more than minimal harm
2025-05-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-08-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-01
F · Potential for more than minimal harm
2023-07-12
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 2023-08-01
E · Potential for more than minimal harm
2023-07-12
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 2023-08-05
E · Potential for more than minimal harm
2023-07-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-07-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-12
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 2023-08-05
D · Potential for more than minimal harm
2023-07-12
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 2023-08-11
D · Potential for more than minimal harm
2023-06-08
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 2023-07-05
Penalties and ownership
What sits behind the stars
$21,645
2025-05-15
Fine
Fine · fine $21,645
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Eagle Pass Ii Enterprises, LLC
Operational/Managerial Control · Organization
Huggins, Linda
Corporate Director · Individual
Thompson, Johnny
Corporate Officer · Individual
Willig, Zachary
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Maverick Nursing and Rehabilitation Center
Eagle Pass, TX
3-star overall rating with 3-star inspections with $15,642 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Eagle Pass Nursing And Rehabilitation
Eagle Pass, TX
2-star overall rating with 3-star inspections with $17,419 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Whispering Springs Rehabilitation And Healthcare C
Carrizo Springs, TX
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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