Cycle 1
Health 2025-02-26 · Fire 2025-02-26
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Waco, TX
St. Catherine Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
300 West Highway 6, Waco, TX
(254) 761-8500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
165
Certified beds
Average residents
144
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1992-01-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 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
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,734
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0017
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.76% · Performance 21.99% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.61
Baseline 8.06% · Performance 6.49% · Measure score 4.61 · Achievement 4.49 · Improvement 4.61
Total nurse turnover
10
Baseline 32.03% · Performance 24.67% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
4.61
Baseline 3.99 hours · Performance 4.39 hours · Measure score 4.61 · Achievement 4.61 · Improvement 1.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.14% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 347 · Observed rate 9.51% · Lower 95% interval 7.8% |
| Discharge to community | 50.18% |
50.57%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 333 · Observed rate 47.75% · Lower 95% interval 45.84% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 37.55% |
95.27%
57.7 pts worse
|
Numerator 86 · Denominator 229 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 229 |
| Discharge self-care score | 51.16% |
53.69%
2.5 pts worse
|
Numerator 88 · Denominator 172 |
| Discharge mobility score | 25.58% |
50.94%
25.4 pts worse
|
Numerator 44 · Denominator 172 |
| Pressure ulcers or injuries, new or worsened | 0.87% |
2.29%
1.4 pts better
|
Numerator 2 · Denominator 229 · Adjusted rate 1.1% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 211 · Observed rate 5.21% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 0.99% |
8.2%
7.2 pts worse
|
Numerator 2 · Denominator 202 |
| Staff flu vaccination coverage | 94.47% |
42%
52.5 pts better
|
Numerator 205 · Denominator 217 |
| Discharge function score | 44.77% |
56.45%
11.7 pts worse
|
Numerator 77 · Denominator 172 |
| Transfer of health information to provider | 88.89% |
95.95%
7.1 pts worse
|
Numerator 64 · Denominator 72 |
| Transfer of health information to patient | 75.86% |
96.28%
20.4 pts worse
|
Numerator 88 · Denominator 116 |
| Resident COVID-19 vaccinations up to date | 40.68% |
25.2%
15.5 pts better
|
Numerator 48 · Denominator 118 |
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 1.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.4 · 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 0.0% · Q2 1.9% · Q3 2.8% · Q4 3.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
2.7%
2.2 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
3.3%
0.3 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 3.5% · Q4 3.7% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
18.9%
3.2 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.3% · Q3 16.7% · Q4 23.3% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
10.8%
5.3 pts worse
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 15.2% · Q3 18.6% · Q4 15.7% · 4Q avg 16.1% · 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 | 20.6% |
15.4%
5.2 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 30.2% · Q3 22.3% · Q4 8.0% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
16.1%
0.8 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 21.0% · Q3 17.6% · Q4 9.9% · 4Q avg 16.9% · 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 | 1.9% |
0.8%
1.1 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 6.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
15.0%
8 pts worse
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 23.5% · Q3 25.0% · Q4 23.8% · 4Q avg 23.0% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.2%
1 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.9% · Q3 4.1% · Q4 3.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
89.7%
8.8 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.3% · Q3 98.8% · Q4 98.8% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.3% |
12.0%
7.3 pts worse
|
12.0%
7.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 18.8% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.0% · Q3 0.5% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
88.0%
9 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
25.9%
0.4 pts better
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 22.3% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-18
F · Potential for more than minimal harm
2025-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-26
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 2025-03-18
F · Potential for more than minimal harm
2024-01-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-01-25
F · Potential for more than minimal harm
2024-01-25
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-01-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-29
F · Potential for more than minimal harm
2024-01-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-21
E · Potential for more than minimal harm
2024-01-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-25
D · Potential for more than minimal harm
2024-01-25
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-03-08
C · Minimal harm
2024-01-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-11-10
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-06-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-10
E · Potential for more than minimal harm
2025-02-26
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 2025-03-18
D · Potential for more than minimal harm
2025-02-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-18
D · Potential for more than minimal harm
2024-09-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-25
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 2024-02-16
D · Potential for more than minimal harm
2023-11-16
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 2023-12-06
F · Potential for more than minimal harm
2022-11-10
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 2022-12-14
F · Potential for more than minimal harm
2022-11-10
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 2022-12-02
Penalties and ownership
What sits behind the stars
Ownership
Ascension Health Senior Care
5% Or Greater Direct Ownership Interest · Organization
Breedlove, Ryan
Corporate Director · Individual
Lefco, Amy
Operational/Managerial Control · Individual
Musgrave, Lisa
Corporate Director · Individual
Pietsch, Darrell
Operational/Managerial Control · Individual
Shadbolt, Erin
Corporate Officer · Individual
Smoot, Kenneth
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Ridgecrest Retirement and Healthcare Community
Waco, TX
2-star overall rating with 2-star inspections with $21,565 in total fines with 14 recent health deficiencies
#2
Woodway Rehabilitation And Healthcare Center
Waco, TX
2-star overall rating with 2-star inspections with $14,953 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Greenview Nursing and Rehabilitation
Waco, TX
1-star overall rating with 1-star inspections with abuse icon flag with $50,213 in total fines with 24 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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