Cycle 1
Health 2025-10-01 · Fire 2024-08-15
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
San Marcos, TX
San Marcos Rehabilitation and Healthcare Center
1-star overall rating with 1-star inspections with $52,140 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1600 N I H 35, San Marcos, TX
(512) 353-5026
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
129
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1997-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
46%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,160
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.42
Baseline 17.81% · Performance 19.85% · Measure score 3.42 · Achievement 3.42 · Improvement 0
Healthcare-associated infections
2.29
Baseline 7.19% · Performance 7.15% · Measure score 2.29 · Achievement 2.29 · Improvement 0
Total nurse turnover
6.23
Baseline 43.75% · Performance 38.23% · Measure score 6.23 · Achievement 6.23 · Improvement 2.42
Adjusted total nurse staffing
0.30
Baseline 2.79 hours · Performance 3.03 hours · Measure score 0.30 · Achievement 0 · Improvement 0.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 6.51% |
| Discharge to community | 53.24% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 50% · Lower 95% interval 41.18% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 83.61% |
95.27%
11.7 pts worse
|
Numerator 51 · Denominator 61 |
| Falls with major injury | 1.64% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 61 |
| Discharge self-care score | 32.61% |
53.69%
21.1 pts worse
|
Numerator 15 · Denominator 46 |
| Discharge mobility score | 17.39% |
50.94%
33.5 pts worse
|
Numerator 8 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 3.28% |
2.29%
1 pts worse
|
Numerator 2 · Denominator 61 · Adjusted rate 2.99% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 131 |
| Staff flu vaccination coverage | 31.64% |
42%
10.4 pts worse
|
Numerator 56 · Denominator 177 |
| Discharge function score | 34.78% |
56.45%
21.7 pts worse
|
Numerator 16 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 85.19% |
96.28%
11.1 pts worse
|
Numerator 23 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 2.78% |
25.2%
22.4 pts worse
|
Numerator 1 · Denominator 36 |
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 | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · 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 | 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 | 2.1% |
3.3%
1.2 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 1.2% · Q4 2.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
2.7%
2.1 pts worse
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.6% · Q3 0.0% · Q4 3.1% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
3.3%
2.9 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 8.0% · Q3 4.2% · Q4 1.4% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
18.9%
5.7 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 15.4% · Q3 13.3% · Q4 10.4% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
10.8%
4 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.8% · Q3 9.7% · Q4 7.8% · 4Q avg 6.8% · 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 | 32.3% |
15.4%
16.9 pts worse
|
16.3%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 52.1% · Q3 24.9% · Q4 31.7% · 4Q avg 32.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.6% |
16.1%
18.5 pts worse
|
14.9%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 56.2% · Q3 38.9% · Q4 25.0% · 4Q avg 34.6% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.5% |
15.0%
1.5 pts better
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 13.9% · Q3 15.7% · Q4 13.7% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.2%
2.1 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 2.0% · Q4 2.8% · 4Q avg 2.1% · 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 | 15.9% |
12.0%
3.9 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 17.3% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.4% |
88.0%
11.4 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
25.9%
11.7 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 15.4% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2023-06-16
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-16 · Fire 2022-04-22
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-15
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 2025-03-21
C · Minimal harm
2024-08-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-21
E · Potential for more than minimal harm
2023-06-16
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 2023-11-25
E · Potential for more than minimal harm
2023-06-16
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 2023-11-25
E · Potential for more than minimal harm
2023-06-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-25
C · Minimal harm
2023-06-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-26
F · Potential for more than minimal harm
2022-04-22
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 2022-05-21
F · Potential for more than minimal harm
2022-04-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-01
K · Immediate jeopardy
2025-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-02
K · Immediate jeopardy
2025-08-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-02
E · Potential for more than minimal harm
2024-11-04
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 2024-12-04
E · Potential for more than minimal harm
2024-11-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-04
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 2024-12-04
E · Potential for more than minimal harm
2024-08-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-14
E · Potential for more than minimal harm
2024-08-15
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 2024-09-14
E · Potential for more than minimal harm
2024-08-15
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 2024-09-14
E · Potential for more than minimal harm
2024-08-15
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 2024-09-14
E · Potential for more than minimal harm
2024-08-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-14
E · Potential for more than minimal harm
2024-08-15
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 2024-09-14
E · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-15
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-09-14
G · Actual harm
2024-04-15
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 2024-05-03
D · Potential for more than minimal harm
2023-06-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-07
Penalties and ownership
What sits behind the stars
$52,140
2025-08-01
Fine
Fine · fine $52,140
Fine
Ownership
Guadalupe County Hospital Board
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Castro Pou, Graciela
Operational/Managerial Control · Individual
Gann, Kody
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Tochterman, Jerry
Operational/Managerial Control · Individual
Wood Bayou Healthcare, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Hays Nursing And Rehabilitation Center
San Marcos, TX
3-star overall rating with 3-star inspections with $8,226 in total fines with 6 recent health deficiencies
#2
Cypress Healthcare and Rehabilitation Center
San Marcos, TX
1-star overall rating with 1-star inspections with $236,732 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Legend Oaks Healthcare and Rehabilitation-Kyle
Kyle, TX
4-star overall rating with 3-star inspections with $12,735 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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