Colorado City, TX

Mitchell County Nursing And Rehabilitation Center

2-star overall rating with 3-star inspections with 10 recent health deficiencies

971 W I 20, Colorado City, TX

(325) 728-5247

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 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

54

Certified beds

Average residents

47

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2009-10-15

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

0.21

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.48

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.61

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.31

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

0.70

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

0.98

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.05

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.27

CMS adjusted RN staffing hours

Adjusted total hours

2.94

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

36%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

409

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

Performance score

70.53

Composite VBP score used to determine payment impact.

Payment multiplier

1.0226

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

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

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

10

Baseline 41.94% · Performance 18.75% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

4.11

Baseline 3.80 hours · Performance 4.25 hours · Measure score 4.11 · Achievement 4.11 · Improvement 1.73

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.8	1.02 0.2 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 63
Staff flu vaccination coverage	30.77%	42% 11.2 pts worse	Numerator 16 · Denominator 52
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 5 · 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	1.8	2.1 0.3 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.2 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	5.7	2.1 3.6 pts worse	1.8 3.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 5.7 · Observed 4.5 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.7%	97.1% 1.4 pts worse	93.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 91.7% · Q3 97.9% · Q4 97.8% · 4Q avg 95.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.0%	97.9% 3.9 pts worse	95.5% 1.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0%
Percentage of long-stay residents experiencing one or more falls with major injury	9.1%	3.3% 5.8 pts worse	3.3% 5.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.4% · Q3 8.5% · Q4 6.7% · 4Q avg 9.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	11.6%	2.7% 8.9 pts worse	11.4% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 13.3% · Q3 2.2% · Q4 0.0% · 4Q avg 11.6%
Percentage of long-stay residents who lose too much weight	0.7%	3.3% 2.6 pts better	5.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 0.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.8%	18.9% 12.9 pts worse	19.6% 12.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 17.5% · Q3 38.5% · Q4 42.4% · 4Q avg 31.8%
Percentage of long-stay residents who received an antipsychotic medication	7.4%	10.8% 3.4 pts better	16.7% 9.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.7% · Q3 6.2% · Q4 3.4% · 4Q avg 7.4% · 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	23.8%	15.4% 8.4 pts worse	16.3% 7.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 30.3% · Q3 22.6% · 4Q avg 23.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.4%	16.1% 5.3 pts worse	14.9% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.8% · Q2 24.3% · Q3 13.2% · Q4 9.4% · 4Q avg 21.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	7.4%	0.5% 6.9 pts worse	1.0% 6.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 4.7% · Q3 9.3% · Q4 9.1% · 4Q avg 7.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.4%	0.8% 3.6 pts worse	1.7% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.2% · Q3 6.8% · Q4 4.4% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.9%	15.0% 1.1 pts better	19.8% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 6.3% · Q3 22.4% · Q4 13.0% · 4Q avg 13.9%
Percentage of long-stay residents with pressure ulcers	2.9%	4.2% 1.3 pts better	5.1% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.8% · Q3 0.0% · Q4 1.9% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.2%	89.7% 0.5 pts better	81.7% 8.5 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 90.2%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-20 · Fire 2025-02-20

10 health deficiencies

Top issue: Resident Rights (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-01-18 · Fire 2024-01-18

4 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2022-11-30 · Fire 2022-11-30

3 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-01-18

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 2024-02-18

C · Minimal harm 2022-11-30

K211 · Egress Deficiencies

Fire Safety

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

Not marked corrected

C · Minimal harm 2022-11-30

K521 · Services Deficiencies

Fire Safety

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

Not marked corrected

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-02-20

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 2025-03-20

F · Potential for more than minimal harm 2025-02-20

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 2025-03-20

E · Potential for more than minimal harm 2025-02-20

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 2025-03-20

D · Potential for more than minimal harm 2025-02-20

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 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F552 · Resident Rights Deficiencies

Health

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

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

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 2025-03-20

D · Potential for more than minimal harm 2025-02-20

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 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-03-20

F · Potential for more than minimal harm 2024-01-18

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 2024-02-18

F · Potential for more than minimal harm 2024-01-18

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 2024-02-18

E · Potential for more than minimal harm 2024-01-18

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-02-18

D · Potential for more than minimal harm 2024-01-18

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-02-18

E · Potential for more than minimal harm 2022-11-30

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-12-30

E · Potential for more than minimal harm 2022-11-30

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 2022-12-30

E · Potential for more than minimal harm 2022-11-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-12-30

Penalties and ownership

What sits behind the stars

Ownership

Mitchell County Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 1967-01-01

Edwards, Helen