Cycle 1
Health 2024-12-12 · Fire 2024-12-12
19 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Georgetown, TX
Park Place Care Center
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $374,871 in total fines with 19 recent health deficiencies
121 Fm 971, Georgetown, TX
(512) 868-6200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
91
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2002-05-24
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
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.77
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,605
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
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
1.31
Baseline 5.55% · Performance 7.44% · Measure score 1.31 · Achievement 1.31 · Improvement 0
Total nurse turnover
6.24
Performance 38.18% · Measure score 6.24 · Achievement 6.24 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.14
Baseline 3.88 hours · Performance 3.69 hours · Measure score 2.14 · Achievement 2.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 9.38% · Lower 95% interval 6.34% |
| Discharge to community | 45.78% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 37.14% · Lower 95% interval 34.8% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92% |
95.27%
3.3 pts worse
|
Numerator 46 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 58.62% |
53.69%
4.9 pts better
|
Numerator 17 · Denominator 29 |
| Discharge mobility score | 55.17% |
50.94%
4.2 pts better
|
Numerator 16 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 50 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.44% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 8.82% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 117 |
| Staff flu vaccination coverage | 12.65% |
42%
29.4 pts worse
|
Numerator 21 · Denominator 166 |
| Discharge function score | 68.97% |
56.45%
12.5 pts better
|
Numerator 20 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 40 |
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 · Adjusted 1.7 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · 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 | 98.9% |
97.9%
1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.3%
0.2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.5% · Q3 3.7% · Q4 3.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
2.7%
0.4 pts worse
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 12.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
3.3%
0.6 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.0% · Q3 1.6% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
18.9%
10.2 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 9.0% · Q3 4.6% · Q4 8.8% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
10.8%
3.5 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.5% · Q3 7.4% · Q4 8.8% · 4Q avg 7.3% · 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 | 9.6% |
15.4%
5.8 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 9.7% · Q3 10.5% · Q4 7.8% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
16.1%
3 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 12.5% · Q3 10.8% · Q4 19.1% · 4Q avg 13.1% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.5% |
15.0%
2.5 pts better
|
19.8%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 15.1% · Q3 11.4% · Q4 12.6% · 4Q avg 12.5% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
4.2%
2.9 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.5% · Q3 1.4% · Q4 0.0% · 4Q avg 1.3% · 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 | 11.4% |
12.0%
0.6 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.4% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.8% |
1.5%
4.3 pts worse
|
1.6%
4.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 8.3% · Q3 2.4% · Q4 0.0% · 4Q avg 5.8% · 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 | 31.6% |
25.9%
5.7 pts worse
|
23.9%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.6% · Observed 28.6% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-09-08 · Fire 2022-09-08
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-10-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-07
E · Potential for more than minimal harm
2023-10-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-07
F · Potential for more than minimal harm
2022-09-08
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-10-10
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-09
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 2026-01-11
J · Immediate jeopardy
2026-01-09
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 2026-01-11
J · Immediate jeopardy
2025-10-06
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 2025-09-03
D · Potential for more than minimal harm
2025-10-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-10-07
K · Immediate jeopardy
2025-07-10
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 2025-07-11
K · Immediate jeopardy
2025-07-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-11
K · Immediate jeopardy
2025-07-10
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 2025-07-11
E · Potential for more than minimal harm
2025-07-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-05-21
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 2025-05-22
D · Potential for more than minimal harm
2025-05-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-11
K · Immediate jeopardy
2025-01-28
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 2025-01-17
K · Immediate jeopardy
2025-01-11
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-01-12
E · Potential for more than minimal harm
2025-01-11
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 2025-01-12
E · Potential for more than minimal harm
2024-12-12
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 2024-12-13
E · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-12-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-12-12
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-12-12
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-12-12
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 2024-12-13
D · Potential for more than minimal harm
2024-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-12-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-10-31
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 2024-11-05
D · Potential for more than minimal harm
2024-10-15
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 2024-11-01
D · Potential for more than minimal harm
2024-10-15
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 2024-11-01
D · Potential for more than minimal harm
2024-07-12
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-07-12
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 2024-07-15
J · Immediate jeopardy
2023-11-11
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 2023-11-15
E · Potential for more than minimal harm
2023-10-26
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 2023-11-07
D · Potential for more than minimal harm
2023-10-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-07
K · Immediate jeopardy
2023-05-02
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 2023-05-12
D · Potential for more than minimal harm
2023-05-02
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 2023-05-12
D · Potential for more than minimal harm
2023-05-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-06
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 2023-05-02
F · Potential for more than minimal harm
2022-09-08
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 2022-09-28
E · Potential for more than minimal harm
2022-09-08
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 2022-09-28
E · Potential for more than minimal harm
2022-09-08
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 2022-09-28
E · Potential for more than minimal harm
2022-09-08
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 2022-09-28
D · Potential for more than minimal harm
2022-09-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-08
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 2022-09-28
Penalties and ownership
What sits behind the stars
$80,135
2026-01-09
Fine
Fine · fine $80,135
Fine
$19,120
2025-10-06
Fine
Fine · fine $19,120
Fine
$19,347
2025-05-21
Fine
Fine · fine $19,347
Fine
$15,538
2025-01-11
Fine
Fine · fine $15,538
Fine
$14,518
2023-10-26
Fine
Fine · fine $14,518
Fine
$226,213
2023-04-06
Fine
Fine · fine $226,213
Fine
Ownership
Guadalupe County Hospital Board
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Gann, Kody
Corporate Officer · Individual
Georgetown I Enterprises, L.l.c.
Operational/Managerial Control · Organization
Huggins, Linda
Corporate Director · Individual
Willig, Zachary
Corporate Director · Individual
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#3
San Gabriel Rehabilitation and Care Center
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