Cycle 1
Health 2024-09-19 · Fire 2024-09-19
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
San Angelo, TX
Regency House
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3745 Summer Crest Dr, San Angelo, TX
(512) 213-5785
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caraday Healthcare
Operator or chain grouping
Approved since
1998-10-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 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
0.26
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
3.19
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,302
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.91
Baseline 20.61% · Performance 18.69% · Measure score 5.91 · Achievement 5.91 · Improvement 4.86
Healthcare-associated infections
0
Baseline 6.81% · Performance 8.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.03
Baseline 67.74% · Performance 61.19% · Measure score 1.03 · Achievement 0.61 · Improvement 1.03
Adjusted total nurse staffing
0
Baseline 3.41 hours · Performance 3.02 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.03% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 15.53% · Lower 95% interval 9.95% |
| Discharge to community | 43.2% |
50.57%
7.4 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 37.31% · Lower 95% interval 35.51% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 6.58% |
95.27%
88.7 pts worse
|
Numerator 5 · Denominator 76 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 76 |
| Discharge self-care score | 67.61% |
53.69%
13.9 pts better
|
Numerator 48 · Denominator 71 |
| Discharge mobility score | 39.44% |
50.94%
11.5 pts worse
|
Numerator 28 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 76 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.89% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 10.78% · Lower 95% interval 6.08% |
| Staff COVID-19 vaccination coverage | 22.09% |
8.2%
13.9 pts better
|
Numerator 19 · Denominator 86 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 57.75% |
56.45%
1.3 pts better
|
Numerator 41 · Denominator 71 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.23% |
96.28%
About the same
|
Numerator 51 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 14.71% |
25.2%
10.5 pts worse
|
Numerator 5 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
2.1
1.8 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
97.1%
0.4 pts worse
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.5% · Q3 96.9% · Q4 93.8% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
97.9%
0.5 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.3%
2.8 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 10.5% · Q3 6.2% · Q4 3.1% · 4Q avg 6.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
18.9%
8.4 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 29.2% · Q3 26.0% · Q4 28.6% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.9% |
10.8%
4.1 pts worse
|
16.7%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 16.2% · Q3 15.4% · Q4 18.6% · 4Q avg 14.9% · 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 | 14.3% |
15.4%
1.1 pts better
|
16.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
16.1%
2 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 17.0% · Q3 8.7% · Q4 12.8% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 1.6% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
15.0%
8.3 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 32.8% · Q3 12.1% · Q4 23.1% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.2%
1 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 1.3% · Q3 2.2% · Q4 3.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
89.7%
6.8 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 98.2% · Q3 95.4% · Q4 94.8% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.5% |
12.0%
10.5 pts better
|
12.0%
10.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.5% · Observed 1.4% · Expected 10.5% · 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% · 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 | 97.6% |
88.0%
9.6 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.0% |
25.9%
9.9 pts better
|
23.9%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 13.7% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-05-26 · Fire 2022-05-26
2 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2026-02-12
F · Potential for more than minimal harm
2024-09-19
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 2024-10-11
F · Potential for more than minimal harm
2024-09-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-19
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 2024-10-11
E · Potential for more than minimal harm
2024-09-19
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 2024-10-11
E · Potential for more than minimal harm
2024-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-19
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 2024-10-11
B · Minimal harm
2024-09-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-29
F · Potential for more than minimal harm
2023-07-27
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 2023-08-18
E · Potential for more than minimal harm
2023-07-27
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 2023-08-18
E · Potential for more than minimal harm
2023-07-27
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 2023-08-18
E · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-18
E · Potential for more than minimal harm
2022-05-26
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 2022-06-13
E · Potential for more than minimal harm
2022-05-26
F910 · Environmental Deficiencies
Health
Ensure resident rooms meet each resident's needs.
Corrected 2022-06-25
Penalties and ownership
What sits behind the stars
Ownership
Stratford Hospital District
5% Or Greater Direct Ownership Interest · Organization
Caraday Regency LLC
Operational/Managerial Control · Organization
Chumley, Richard
Corporate Officer · Individual
Granite Regency, LLC
5% Or Greater Mortgage Interest · Organization
Moore, Gregory
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Meadow Creek Nursing And Rehabilitation
San Angelo, TX
3-star overall rating with 2-star inspections with $119,203 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Avir At San Angelo
San Angelo, TX
1-star overall rating with 1-star inspections with $241,795 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
St. Juanita Retirement and Rehab
San Angelo, TX
0-star overall rating with 0-star inspections
Jump out