Cycle 1
Health 2025-08-13 · Fire 2025-08-13
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Carthage, TX
Panola County Nursing & Rehabilitation
2-star overall rating with 3-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
501 Cottage Rd, Carthage, TX
(903) 693-7141
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
108
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gulf Coast Ltc Partners
Operator or chain grouping
Approved since
1994-09-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.24
Registered nurse staffing
LPN hours / resident day
1.04
Licensed practical nurse staffing
Aide hours / resident day
1.66
Nurse aide staffing
Weekend hours
2.51
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.8% |
3.3%
2.5 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
18.9%
0.7 pts worse
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
10.8%
8.1 pts worse
|
16.7%
2.2 pts worse
|
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 | 12.6% |
15.4%
2.8 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.3% |
16.1%
17.2 pts worse
|
14.9%
18.4 pts worse
|
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 | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.7% |
15.0%
5.3 pts better
|
19.8%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.2%
1.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
89.7%
8.7 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
16 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-05
C · Minimal harm
2025-08-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Not marked corrected
E · Potential for more than minimal harm
2024-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-06-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-06-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-06-05
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 2024-08-30
D · Potential for more than minimal harm
2024-06-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-30
B · Minimal harm
2024-06-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Not marked corrected
B · Minimal harm
2023-04-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Not marked corrected
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-08-13
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 2025-09-13
D · Potential for more than minimal harm
2025-08-13
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 2025-09-13
D · Potential for more than minimal harm
2025-08-13
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 2025-09-13
D · Potential for more than minimal harm
2025-08-13
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 2025-09-13
D · Potential for more than minimal harm
2025-08-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-08-13
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 2025-09-13
D · Potential for more than minimal harm
2025-08-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-08-13
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-08-13
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 2025-09-13
D · Potential for more than minimal harm
2025-08-13
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 2025-09-13
D · Potential for more than minimal harm
2025-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-13
E · Potential for more than minimal harm
2024-06-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
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 2024-07-03
E · Potential for more than minimal harm
2024-06-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
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 2024-07-03
E · Potential for more than minimal harm
2024-06-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-05
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 2024-07-03
D · Potential for more than minimal harm
2024-06-05
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-05
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 2024-07-03
D · Potential for more than minimal harm
2024-06-05
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 2024-07-03
D · Potential for more than minimal harm
2024-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-05
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 2024-07-03
D · Potential for more than minimal harm
2024-06-05
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-05
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-07-03
E · Potential for more than minimal harm
2023-04-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-04-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-04-19
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 2023-04-30
E · Potential for more than minimal harm
2023-04-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-04-19
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 2023-04-30
D · Potential for more than minimal harm
2023-04-19
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 2023-04-30
Penalties and ownership
What sits behind the stars
Ownership
South Limestone Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bergeron, Bobby
Operational/Managerial Control · Individual
Carthage Ltc Partners, Inc.
Operational/Managerial Control · Organization
Nicholson, Louis
Operational/Managerial Control · Individual
Price, Larry
Corporate Officer · Individual
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#3
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