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
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
Weekend hours
0.00
Weekend nurse staffing
RN turnover
46%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Jump out