Cycle 1
Health 2025-04-16 · Fire 2025-04-16
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Rockdale, TX
Rockdale Estates & Rehabilitation
2-star overall rating with 4-star inspections with $8,018 in total fines with 7 recent health deficiencies
1350 W. Highway 79, Rockdale, TX
(512) 446-2548
Overall
2 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fannin County Hospital District
Operator or chain grouping
Approved since
2006-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 2 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
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.76
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.90
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.52
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,625
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
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
0
Baseline 8.37% · Performance 9.12% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.82
Baseline 57.89% · Performance 60.35% · Measure score 0.82 · Achievement 0.82 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.06 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 8.51% · Lower 95% interval 6.45% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.63 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 94.29% |
95.27%
1 pts worse
|
Numerator 33 · Denominator 35 |
| Falls with major injury | 5.71% |
0.77%
4.9 pts worse
|
Numerator 2 · Denominator 35 |
| Discharge self-care score | 23.08% |
53.69%
30.6 pts worse
|
Numerator 6 · Denominator 26 |
| Discharge mobility score | 23.08% |
50.94%
27.9 pts worse
|
Numerator 6 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 35 · Adjusted rate 4.61% |
| Healthcare-associated infections requiring hospitalization | 9.12% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 16.67% · Lower 95% interval 5.4% |
| Staff COVID-19 vaccination coverage | 5.77% |
8.2%
2.4 pts worse
|
Numerator 3 · Denominator 52 |
| Staff flu vaccination coverage | 34.88% |
42%
7.1 pts worse
|
Numerator 30 · Denominator 86 |
| Discharge function score | 15.38% |
56.45%
41.1 pts worse
|
Numerator 4 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 7 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.1 |
2.1
2 pts worse
|
1.8
2.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.1 · Observed 3.7 · Expected 1.5 · 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 | 98.6% |
97.9%
0.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.7% |
3.3%
5.4 pts worse
|
3.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.8% · Q3 8.8% · Q4 8.5% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.1% |
2.7%
7.4 pts worse
|
11.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 9.8% · Q3 10.2% · Q4 12.7% · 4Q avg 10.1% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
3.3%
2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 3.3% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.5% |
18.9%
8.6 pts worse
|
19.6%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 28.4% · Q3 26.9% · Q4 24.6% · 4Q avg 27.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
10.8%
2.2 pts worse
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 14.0% · Q3 13.8% · Q4 12.3% · 4Q avg 13.0% · 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 | 21.5% |
15.4%
6.1 pts worse
|
16.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 27.0% · Q3 24.7% · Q4 16.1% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.1% |
16.1%
5 pts worse
|
14.9%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 23.9% · Q3 25.8% · Q4 13.2% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 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 a urinary tract infection | 4.1% |
0.8%
3.3 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.6% · Q3 8.1% · Q4 4.8% · 4Q avg 4.1% · 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 21.9% · Q2 36.1% · Q3 16.0% · Q4 18.5% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
4.2%
2.3 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.3% · Q3 5.7% · Q4 6.7% · 4Q avg 6.5% · 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 · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.6% |
12.0%
5.6 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 16.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.0% |
1.5%
6.5 pts worse
|
1.6%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.4% |
25.9%
12.5 pts worse
|
23.9%
14.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.4% · Observed 27.8% · Expected 17.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
2 health deficiencies
Top issue: Infection Control (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
2024-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-03-07
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-03-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-16
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 2025-05-12
D · Potential for more than minimal harm
2025-04-16
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 2025-05-12
D · Potential for more than minimal harm
2025-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-16
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 2025-05-12
D · Potential for more than minimal harm
2025-04-16
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 2025-05-12
D · Potential for more than minimal harm
2025-04-16
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 2025-05-12
D · Potential for more than minimal harm
2025-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-12
G · Actual harm
2024-03-20
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 2024-04-10
F · Potential for more than minimal harm
2024-03-07
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 2024-04-15
E · Potential for more than minimal harm
2024-03-07
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 2024-04-15
D · Potential for more than minimal harm
2024-03-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-15
D · Potential for more than minimal harm
2023-11-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-06
Penalties and ownership
What sits behind the stars
$8,018
2024-03-07
Fine
Fine · fine $8,018
Fine
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Johnson 5.0 LLC
Operational/Managerial Control · Organization
Johnson, Jeffrey
Operational/Managerial Control · Individual
Sanderson, Clark
Corporate Director · Individual
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