Cycle 1
Health 2025-09-10 · Fire 2025-09-10
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Italy, TX
Renaissance Rehabilitation And Healthcare Center
5-star overall rating with 5-star inspections with 4 recent health deficiencies
220 Davenport St, Italy, TX
(972) 483-6369
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
61
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
1992-07-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,548
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.37
Baseline 19.77% · Performance 19.87% · Measure score 3.37 · Achievement 3.37 · Improvement 0
Healthcare-associated infections
3.23
Baseline 5.95% · Performance 6.87% · Measure score 3.23 · Achievement 3.23 · Improvement 0
Total nurse turnover
2.72
Baseline 60.00% · Performance 52.54% · Measure score 2.72 · Achievement 2.72 · Improvement 1.62
Adjusted total nurse staffing
0
Baseline 3.12 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.15% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 17.95% · Lower 95% interval 7.99% |
| Discharge to community | 57.26% |
50.57%
6.7 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 48.33% · Lower 95% interval 42.9% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 87.5% |
95.27%
7.8 pts worse
|
Numerator 21 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.87% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 74 |
| Staff flu vaccination coverage | 10.47% |
42%
31.5 pts worse
|
Numerator 9 · Denominator 86 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
97.1%
6.2 pts worse
|
93.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.2% · Q3 90.4% · Q4 75.0% · 4Q avg 90.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
97.9%
3.1 pts worse
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.6% · Q3 7.7% · Q4 7.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
2.7%
2.2 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
3.3%
2.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
18.9%
5.3 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 13.6% · Q3 16.7% · Q4 15.2% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.0% |
10.8%
14.2 pts worse
|
16.7%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 21.9% · Q3 25.0% · Q4 31.4% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.4% |
0.0%
1.4 pts worse
|
0.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.9% · Q4 1.8% · 4Q avg 1.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
15.4%
6.4 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · 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 9.3% · Q2 11.9% · Q3 17.1% · Q4 18.2% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 | 9.6% |
15.0%
5.4 pts better
|
19.8%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 11.1% · Q3 7.3% · Q4 8.8% · 4Q avg 9.6% |
| 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 1.2% · Q2 2.5% · Q3 0.0% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.7% |
89.7%
20 pts worse
|
81.7%
12 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 91.7% · Q3 52.2% · Q4 40.4% · 4Q avg 69.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
12.0%
3.1 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 3.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.2% |
88.0%
20.8 pts worse
|
79.7%
12.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.9% |
25.9%
12 pts worse
|
23.9%
14 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.9% · Observed 40.9% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-22 · Fire 2024-08-22
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-12
F · Potential for more than minimal harm
2024-08-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-12
E · Potential for more than minimal harm
2024-08-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-12
E · Potential for more than minimal harm
2024-08-22
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-02-12
D · Potential for more than minimal harm
2024-08-22
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 2025-02-12
F · Potential for more than minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-10
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 2025-09-25
D · Potential for more than minimal harm
2025-09-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-10
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 2025-09-25
D · Potential for more than minimal harm
2025-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-25
E · Potential for more than minimal harm
2023-08-03
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 2023-08-04
E · Potential for more than minimal harm
2023-06-29
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 2023-06-30
E · Potential for more than minimal harm
2023-06-29
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 2023-06-30
E · Potential for more than minimal harm
2023-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-06-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-29
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 2023-06-30
D · Potential for more than minimal harm
2023-06-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Fallon, John
Operational/Managerial Control · Individual
Herdrich, William
Operational/Managerial Control · Individual
Kirley, Francis
Operational/Managerial Control · Individual
Lee, Brian
Operational/Managerial Control · Individual
Mak, David
Corporate Officer · Individual
Mcquery, Jennifer
W-2 Managing Employee · Individual
Nexion Health At Italy, Inc.
Operational/Managerial Control · Organization
Reid, John
Operational/Managerial Control · Individual
Riner, Meera
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pleasant Manor Healthcare Rehabilitation
Waxahachie, TX
3-star overall rating with 3-star inspections with $14,996 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Avir at Itasca
Itasca, TX
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Focused Care of Waxahachie
Waxahachie, TX
1-star overall rating with 1-star inspections with $159,939 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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