Lampasas, TX

Lampasas Nursing and Rehabilitation Center

1-star overall rating with 2-star inspections with $11,440 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

611 N Broad St, Lampasas, TX

(512) 556-3588

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

68

Certified beds

Average residents

30

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Diversicare Healthcare

Operator or chain grouping

Approved since

1985-04-26

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

44 facilities

Chain averages 3 overall / 3 health / 3 staffing / 3 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

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

10,895

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

Performance score

18.71

Composite VBP score used to determine payment impact.

Payment multiplier

0.9820

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.58

Performance 21.16% · Measure score 0.58 · Achievement 0.58 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

3.72

Baseline 53.12% · Performance 48.48% · Measure score 3.72 · Achievement 3.72 · Improvement 1.14

Adjusted total nurse staffing

1.31

Baseline 3.5 hours · Performance 3.45 hours · Measure score 1.31 · Achievement 1.31 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.23%	10.72% 1.5 pts better	No Different than the National Rate · Eligible stays 46 · Observed rate 2.17% · Lower 95% interval 5.84%
Discharge to community	61.54%	50.57% 11 pts better	No Different than the National Rate · Eligible stays 37 · Observed rate 64.86% · Lower 95% interval 44.54%
Medicare spending per beneficiary	0.93	1.02 0.1 pts better
Drug regimen review with follow-up	93.94%	95.27% 1.3 pts worse	Numerator 31 · Denominator 33
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 33
Discharge self-care score	50%	53.69% 3.7 pts worse	Numerator 10 · Denominator 20
Discharge mobility score	55%	50.94% 4.1 pts better	Numerator 11 · Denominator 20
Pressure ulcers or injuries, new or worsened	3.03%	2.29% 0.7 pts worse	Numerator 1 · Denominator 33 · Adjusted rate 2.99%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	2.7%	8.2% 5.5 pts worse	Numerator 1 · Denominator 37
Staff flu vaccination coverage	94.12%	42% 52.1 pts better	Numerator 32 · Denominator 34
Discharge function score	55%	56.45% 1.5 pts worse	Numerator 11 · Denominator 20
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	10%	25.2% 15.2 pts worse	Numerator 2 · Denominator 20

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.4%	97.1% 6.7 pts worse	93.4% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 82.1% · Q3 89.3% · Q4 100.0% · 4Q avg 90.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.9%	97.9% 4 pts worse	95.5% 1.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9%
Percentage of long-stay residents experiencing one or more falls with major injury	5.3%	3.3% 2 pts worse	3.3% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 3.6% · Q3 3.6% · Q4 3.6% · 4Q avg 5.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	18.2%	2.7% 15.5 pts worse	11.4% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 30.4% · Q3 0.0% · 4Q avg 18.2%
Percentage of long-stay residents who lose too much weight	3.0%	3.3% 0.3 pts better	5.4% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.0% · Q3 0.0% · Q4 0.0% · 4Q avg 3.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.4%	18.9% 1.5 pts worse	19.6% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.0% · Q3 30.8% · Q4 28.0% · 4Q avg 20.4%
Percentage of long-stay residents who received an antipsychotic medication	23.2%	10.8% 12.4 pts worse	16.7% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q3 30.0% · Q4 26.1% · 4Q avg 23.2% · 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	21.4%	15.4% 6 pts worse	16.3% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 21.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	27.4%	16.1% 11.3 pts worse	14.9% 12.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 33.3% · Q3 16.0% · Q4 30.4% · 4Q avg 27.4% · 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	25.2%	15.0% 10.2 pts worse	19.8% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 31.9% · Q3 33.1% · Q4 6.7% · 4Q avg 25.2%
Percentage of long-stay residents with pressure ulcers	6.8%	4.2% 2.6 pts worse	5.1% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.7% · Q3 9.6% · Q4 9.3% · 4Q avg 6.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	72.6%	89.7% 17.1 pts worse	81.7% 9.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 69.0% · Q3 76.9% · Q4 90.9% · 4Q avg 72.6%
Percentage of short-stay residents who had an outpatient emergency department visit	10.3%	12.0% 1.7 pts better	12.0% 1.7 pts better	Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 11.5% · Expected 12.5% · 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% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.0%	88.0% 12 pts worse	79.7% 3.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.1%	25.9% 2.8 pts better	23.9% 0.8 pts better	Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 26.9% · Expected 27.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-31 · Fire 2024-10-31

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-09-13 · Fire 2023-09-13

3 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-06-16 · Fire 2022-06-16

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-10-31

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 2025-03-05

C · Minimal harm 2024-10-31

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2025-03-05

C · Minimal harm 2024-10-31

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-03-05

C · Minimal harm 2023-09-13

K211 · Egress Deficiencies

Fire Safety

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

Not marked corrected

C · Minimal harm 2023-09-13

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2022-06-16

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 2023-05-15

D · Potential for more than minimal harm 2022-06-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-15

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-08

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 2026-01-19

J · Immediate jeopardy 2025-11-23

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-11-24

J · Immediate jeopardy 2025-06-13

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-14

D · Potential for more than minimal harm 2024-12-06

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 2024-12-07

E · Potential for more than minimal harm 2024-10-31

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 2024-11-01

D · Potential for more than minimal harm 2024-10-31

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 2024-11-01

D · Potential for more than minimal harm 2024-10-31

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-11-01

D · Potential for more than minimal harm 2024-10-31

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 2024-11-01

D · Potential for more than minimal harm 2024-04-05

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-04-25

D · Potential for more than minimal harm 2023-09-13

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-10-09

F · Potential for more than minimal harm 2022-06-16

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 2022-07-15

D · Potential for more than minimal harm 2022-06-16

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-07-15

D · Potential for more than minimal harm 2022-06-16

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 2022-07-15

Penalties and ownership

What sits behind the stars

$11,440 2025-06-13

Fine

Fine · fine $11,440

Fine

Ownership

Dewitt Medical District

5% Or Greater Direct Ownership Interest · Organization

100% 12 facilities 2019-04-01

Casey, Scottie

W-2 Managing Employee · Individual

0% 1 facilities 2019-04-01

Frels, John

Corporate Director · Individual

0% 5 facilities 2014-11-04

Papacek, Charles

Corporate Director · Individual

0% 6 facilities 1997-10-01

Papacek, Charles