Cycle 1
Health 2024-12-18 · Fire 2024-12-18
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Waco, TX
The Brazos of Waco
1-star overall rating with 1-star inspections with $64,603 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2430 Market Place Drive, Waco, TX
(254) 981-7900
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
123
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2016-11-02
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
0.35
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.90
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.50
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
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.71
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,338
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
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
3.02
Baseline 6.04% · Performance 6.93% · Measure score 3.02 · Achievement 3.02 · Improvement 0
Total nurse turnover
0.82
Baseline 63.79% · Performance 60.35% · Measure score 0.82 · Achievement 0.82 · Improvement 0.39
Adjusted total nurse staffing
0
Baseline 3.28 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 11.48% · Lower 95% interval 6.54% |
| Discharge to community | 62.01% |
50.57%
11.4 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 55.36% · Lower 95% interval 47.46% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 54.17% |
53.69%
0.5 pts better
|
Numerator 13 · Denominator 24 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 8 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 7.69% |
8.2%
0.5 pts worse
|
Numerator 7 · Denominator 91 |
| Staff flu vaccination coverage | 37.18% |
42%
4.8 pts worse
|
Numerator 29 · Denominator 78 |
| Discharge function score | 54.17% |
56.45%
2.3 pts worse
|
Numerator 13 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 1.4% |
3.3%
1.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.8% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
2.7%
0.7 pts worse
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.2% · Q3 1.9% · Q4 1.9% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
3.3%
0.8 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.3% · Q3 2.0% · Q4 1.9% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
18.9%
7.3 pts better
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 8.3% · Q3 11.5% · Q4 12.5% · 4Q avg 11.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
10.8%
5.1 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.7% · Q3 4.9% · Q4 6.5% · 4Q avg 5.7% · 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 | 24.4% |
15.4%
9 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 24.6% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
16.1%
0.9 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 11.9% · Q3 15.6% · Q4 16.7% · 4Q avg 15.2% · 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 | 12.5% |
15.0%
2.5 pts better
|
19.8%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 5.0% · Q3 12.0% · Q4 3.9% · 4Q avg 12.5% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
4.2%
3.5 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.4% · Q3 7.3% · Q4 10.0% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
89.7%
6.9 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 95.1% · Q4 92.8% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
12.0%
2.3 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 14.8% · Expected 11.6% · 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 | 95.8% |
88.0%
7.8 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
25.9%
3.4 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 33.3% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-01 · Fire 2022-09-01
11 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-12-18
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-23
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 2026-02-23
J · Immediate jeopardy
2025-09-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-20
J · Immediate jeopardy
2025-08-28
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 2025-08-29
D · Potential for more than minimal harm
2025-08-28
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 2025-08-29
D · Potential for more than minimal harm
2025-07-30
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-01
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 2025-07-09
K · Immediate jeopardy
2025-03-20
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 2025-03-21
K · Immediate jeopardy
2025-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-21
J · Immediate jeopardy
2025-02-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-27
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 2025-03-19
E · Potential for more than minimal harm
2025-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-28
E · Potential for more than minimal harm
2025-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-28
E · Potential for more than minimal harm
2025-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-28
E · Potential for more than minimal harm
2024-12-18
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 2025-01-10
E · Potential for more than minimal harm
2024-12-18
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 2025-01-10
E · Potential for more than minimal harm
2024-12-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-18
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 2025-01-10
J · Immediate jeopardy
2024-11-24
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 2024-11-23
E · Potential for more than minimal harm
2024-02-28
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-02-28
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-01-16
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 2024-02-13
F · Potential for more than minimal harm
2023-10-26
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 2023-11-16
E · Potential for more than minimal harm
2023-10-26
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 2023-11-16
D · Potential for more than minimal harm
2023-10-26
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 2023-11-16
E · Potential for more than minimal harm
2023-09-01
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 2023-09-21
D · Potential for more than minimal harm
2023-07-14
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 2023-07-15
D · Potential for more than minimal harm
2023-07-14
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.
Corrected 2023-07-15
E · Potential for more than minimal harm
2022-09-01
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-09-03
E · Potential for more than minimal harm
2022-09-01
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 2022-09-03
D · Potential for more than minimal harm
2022-09-01
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-09-03
Penalties and ownership
What sits behind the stars
$24,845
2025-09-26
Fine
Fine · fine $24,845
Fine
$25,325
2025-02-27
Fine
Fine · fine $25,325
Fine
$14,433
2024-11-24
Fine
Fine · fine $14,433
Fine
Ownership
South Limestone Hospital District
5% Or Greater Direct Ownership Interest · Organization
Boswell, James
Operational/Managerial Control · Individual
Market Place Healthcare LLC
Operational/Managerial Control · Organization
Price, Larry
Corporate Officer · Individual
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#3
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