Cycle 1
Health 2025-01-16 · Fire 2025-01-16
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Rockwall, TX
Rockwall Nursing Care Center
2-star overall rating with 2-star inspections with $66,755 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
206 Storrs, Rockwall, TX
(972) 771-5000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
192
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1994-10-17
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 6.48% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 82.76% |
95.27%
12.5 pts worse
|
Numerator 24 · Denominator 29 |
| Falls with major injury | 6.9% |
0.77%
6.1 pts worse
|
Numerator 2 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 1 · Denominator 29 · Adjusted rate 2.04% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 97 |
| Staff flu vaccination coverage | 6.04% |
42%
36 pts worse
|
Numerator 9 · Denominator 149 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · 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 | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
3.3%
3.8 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 7.7% · Q3 7.1% · Q4 6.0% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
2.7%
2 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.2% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
3.3%
0.6 pts worse
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 1.7% · Q3 4.5% · Q4 1.4% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
18.9%
1.4 pts worse
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 21.9% · Q3 20.0% · Q4 19.4% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
10.8%
5.7 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 19.5% · Q3 13.0% · Q4 13.5% · 4Q avg 16.5% · 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 | 9.0% |
15.4%
6.4 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.6% · Q3 9.7% · Q4 9.7% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
16.1%
6.4 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 7.9% · Q3 10.0% · Q4 8.5% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · 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 0.0% · Q2 0.0% · Q3 1.2% · 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 | 16.4% |
15.0%
1.4 pts worse
|
19.8%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 11.1% · Q3 16.1% · Q4 23.3% · 4Q avg 16.4% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.2%
1.3 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.5% · Q3 2.6% · Q4 3.9% · 4Q avg 2.9% · 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 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% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-18 · Fire 2023-11-18
21 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
12 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-16
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-01-25
E · Potential for more than minimal harm
2025-01-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-25
E · Potential for more than minimal harm
2025-01-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-25
C · Minimal harm
2025-01-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-24
C · Minimal harm
2025-01-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-25
F · Potential for more than minimal harm
2023-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-11-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-11-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-16
C · Minimal harm
2023-11-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-16
C · Minimal harm
2023-11-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-16
E · Potential for more than minimal harm
2022-09-29
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 2022-10-01
E · Potential for more than minimal harm
2022-09-29
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-10-10
C · Minimal harm
2022-09-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-30
C · Minimal harm
2022-09-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-01
C · Minimal harm
2022-09-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-11-25
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.
Not marked corrected
D · Potential for more than minimal harm
2025-11-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Not marked corrected
J · Immediate jeopardy
2025-10-21
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 2025-09-29
D · Potential for more than minimal harm
2025-10-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-10-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-06-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-18
E · Potential for more than minimal harm
2025-01-16
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 2025-01-17
E · Potential for more than minimal harm
2025-01-16
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 2025-01-17
E · Potential for more than minimal harm
2025-01-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-12-19
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 2024-12-20
D · Potential for more than minimal harm
2024-12-19
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 2024-12-20
J · Immediate jeopardy
2024-11-01
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 2024-10-31
D · Potential for more than minimal harm
2024-11-01
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 2024-11-02
D · Potential for more than minimal harm
2024-10-09
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-05-17
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 2024-06-06
D · Potential for more than minimal harm
2024-05-17
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 2024-06-06
D · Potential for more than minimal harm
2024-05-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-06-06
K · Immediate jeopardy
2023-11-18
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 2023-11-19
J · Immediate jeopardy
2023-11-18
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 2023-11-19
E · Potential for more than minimal harm
2023-11-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-19
E · Potential for more than minimal harm
2023-11-18
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 2023-11-19
E · Potential for more than minimal harm
2023-11-18
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 2023-11-19
E · Potential for more than minimal harm
2023-11-18
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 2023-11-19
D · Potential for more than minimal harm
2023-11-18
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 2023-11-19
D · Potential for more than minimal harm
2023-11-18
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 2023-11-19
D · Potential for more than minimal harm
2023-11-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-11-18
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 2023-11-19
D · Potential for more than minimal harm
2023-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-19
E · Potential for more than minimal harm
2023-10-03
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-20
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-02
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 2023-08-30
D · Potential for more than minimal harm
2023-08-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-26
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-26
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-25
J · Immediate jeopardy
2023-03-09
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 2023-03-10
J · Immediate jeopardy
2023-03-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-10
F · Potential for more than minimal harm
2022-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-01
E · Potential for more than minimal harm
2022-09-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-09-29
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 2022-11-01
D · Potential for more than minimal harm
2022-09-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-11-01
Penalties and ownership
What sits behind the stars
$24,845
2025-10-21
Fine
Fine · fine $24,845
Fine
$15,897
2024-11-01
Fine
Fine · fine $15,897
Fine
$26,013
2023-11-18
Fine
Fine · fine $26,013
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Honor X Enterprises, LLC
Operational/Managerial Control · Organization
Huggins, Linda
Operational/Managerial Control · Individual
Mak, David
Corporate Officer · Individual
Rockwall I Enterprises LLC
Operational/Managerial Control · Organization
Willig, Zachary
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Highland Meadows
Rockwall, TX
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Beacon Harbor Healthcare And Rehabilitation
Rockwall, TX
4-star overall rating with 3-star inspections with $29,521 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Rowlett Health And Rehabilitation Center
Rowlett, TX
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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