Cycle 1
Health 2025-02-21 · Fire 2025-02-21
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
1205 Santa Fe Dr, TX
Santa Fe Health & Rehabilitation Center
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1205 Santa Fe Dr, 1205 Santa Fe Dr, TX
(817) 594-2786
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Healthcare Solutions
Operator or chain grouping
Approved since
1991-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 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
0.59
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.83
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.30
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
27%
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
5,256
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9901
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
4.23
Baseline 6.45% · Performance 6.57% · Measure score 4.23 · Achievement 4.23 · Improvement 0
Total nurse turnover
5.95
Baseline 90.77% · Performance 48.28% · Measure score 5.95 · Achievement 3.77 · Improvement 5.95
Adjusted total nurse staffing
0.87
Baseline 3.34 hours · Performance 3.33 hours · Measure score 0.87 · Achievement 0.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 10.2% · Lower 95% interval 6.48% |
| Discharge to community | 47.61% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 38.71% · Lower 95% interval 33.84% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 6.25% |
0.77%
5.5 pts worse
|
Numerator 3 · Denominator 48 |
| Discharge self-care score | 64.29% |
53.69%
10.6 pts better
|
Numerator 18 · Denominator 28 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 14 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 48 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 22.89% |
42%
19.1 pts worse
|
Numerator 19 · Denominator 83 |
| Discharge function score | 60.71% |
56.45%
4.3 pts better
|
Numerator 17 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16% |
25.2%
9.2 pts worse
|
Numerator 4 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.8 · Expected 1.8 · 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 | 98.8% |
97.9%
0.9 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.3%
0.4 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.5% · Q3 4.1% · Q4 1.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
2.7%
1.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 1.5% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
3.3%
1.6 pts worse
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.5% · Q3 3.3% · Q4 1.9% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
18.9%
8.2 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 26.5% · Q3 26.2% · Q4 26.7% · 4Q avg 27.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.6% |
10.8%
6.2 pts better
|
16.7%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.1% · Q3 2.3% · Q4 10.2% · 4Q avg 4.6% · 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 | 23.9% |
15.4%
8.5 pts worse
|
16.3%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 29.2% · Q3 21.2% · Q4 37.5% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
16.1%
1 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 19.7% · Q3 11.5% · Q4 31.0% · 4Q avg 17.1% · 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 | 0.0% |
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 | 19.4% |
15.0%
4.4 pts worse
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 26.1% · Q3 15.7% · Q4 16.6% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.2%
0.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.7% · Q3 4.7% · Q4 5.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.7%
9.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.8% |
12.0%
6.8 pts worse
|
12.0%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 23.3% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
88.0%
10 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
25.9%
4.5 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 23.3% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-11-04 · Fire 2022-11-04
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-02-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-28
C · Minimal harm
2025-02-21
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
F · Potential for more than minimal harm
2024-01-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-01-25
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 2024-03-15
C · Minimal harm
2024-01-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-15
C · Minimal harm
2022-11-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-08-08
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 2025-08-11
D · Potential for more than minimal harm
2025-08-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-11
F · Potential for more than minimal harm
2025-02-21
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 2025-03-14
E · Potential for more than minimal harm
2025-02-21
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-21
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 2025-03-14
E · Potential for more than minimal harm
2024-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-01-25
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 2024-03-15
D · Potential for more than minimal harm
2024-01-25
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-01-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-01-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-01-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-01-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-15
F · Potential for more than minimal harm
2022-11-04
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 2022-12-04
E · Potential for more than minimal harm
2022-11-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-04
E · Potential for more than minimal harm
2022-11-04
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 2022-12-04
D · Potential for more than minimal harm
2022-11-04
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-12-04
Penalties and ownership
What sits behind the stars
Ownership
Advanced Hcs LLC
Operational/Managerial Control · Organization
Korkmas, Ross
Corporate Officer · Individual
Korkmas, Ross
W-2 Managing Employee · Individual
Lichtschein, Teddy
Operational/Managerial Control · Individual
Palo Pinto County Hospital District
5% Or Greater Indirect Ownership Interest · Organization
Scheiner, Eliezer
Operational/Managerial Control · Individual
Shelby, Jack
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Holland Lake Rehabilitation And Wellness Center
Weatherford, TX
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Hilltop Park Rehabilitation And Care Center
Weatherford, TX
2-star overall rating with 3-star inspections with $102,810 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
College Park Rehabilitation And Care Center
Weatherford, TX
2-star overall rating with 3-star inspections with $233,175 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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