Cycle 1
Health 2024-10-31 · Fire 2024-10-31
8 health deficiencies
Top issue: Environmental (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Round Rock, TX
Trinity Care Center
2-star overall rating with 2-star inspections with abuse icon flag with $10,293 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1000 E Main St, Round Rock, TX
(512) 634-3000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
179
Certified beds
Average residents
143
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caraday Healthcare
Operator or chain grouping
Approved since
1995-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 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
0.24
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,276
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.49
Baseline 22.18% · Performance 18.58% · Measure score 6.49 · Achievement 6.15 · Improvement 6.49
Healthcare-associated infections
3.85
Baseline 6.00% · Performance 6.69% · Measure score 3.85 · Achievement 3.85 · Improvement 0
Total nurse turnover
1.75
Baseline 55.21% · Performance 56.52% · Measure score 1.75 · Achievement 1.75 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.55 hours · Performance 2.88 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.48% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 6.25% · Lower 95% interval 6.67% |
| Discharge to community | 48.43% |
50.57%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 44.3% · Lower 95% interval 38.99% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 82.35% |
95.27%
12.9 pts worse
|
Numerator 56 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 35.42% |
53.69%
18.3 pts worse
|
Numerator 17 · Denominator 48 |
| Discharge mobility score | 45.83% |
50.94%
5.1 pts worse
|
Numerator 22 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 2.94% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 68 · Adjusted rate 2.49% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 5.56% · Lower 95% interval 4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 40.32% |
42%
1.7 pts worse
|
Numerator 50 · Denominator 124 |
| Discharge function score | 47.92% |
56.45%
8.5 pts worse
|
Numerator 23 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
97.1%
5.1 pts worse
|
93.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 91.9% · Q3 90.4% · Q4 89.8% · 4Q avg 92.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
97.9%
0.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.2% |
3.3%
4.9 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.6% · Q3 8.8% · Q4 8.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
2.7%
2.5 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
3.3%
4.5 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 12.3% · Q3 3.4% · Q4 7.4% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
18.9%
1.3 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 20.5% · Q3 15.7% · Q4 16.1% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
10.8%
3 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 10.3% · Q3 7.5% · Q4 7.5% · 4Q avg 7.8% · 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 | 16.3% |
15.4%
0.9 pts worse
|
16.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 12.7% · Q3 18.6% · Q4 21.8% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
16.1%
2.5 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 12.5% · Q3 16.2% · Q4 16.5% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.5%
0.7 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 2.1% · Q3 1.2% · Q4 0.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.7% |
15.0%
4.7 pts worse
|
19.8%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 23.9% · Q3 21.4% · Q4 16.0% · 4Q avg 19.7% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.2%
1.2 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.4% · Q3 1.9% · Q4 2.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.5% |
89.7%
23.2 pts worse
|
81.7%
15.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 69.2% · Q3 55.4% · Q4 44.3% · 4Q avg 66.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
12.0%
1.9 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 14.3% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.2% |
88.0%
16.8 pts worse
|
79.7%
8.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.8% |
25.9%
10.1 pts better
|
23.9%
8.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 14.3% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
B · Minimal harm
2024-10-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2022-06-09
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-08-29
C · Minimal harm
2022-06-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-07-09
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 2025-07-21
E · Potential for more than minimal harm
2025-07-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-21
E · Potential for more than minimal harm
2025-07-09
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 2025-07-21
D · Potential for more than minimal harm
2025-06-18
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-25
F · Potential for more than minimal harm
2024-10-31
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 2024-11-21
D · Potential for more than minimal harm
2024-10-31
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 2024-11-21
D · Potential for more than minimal harm
2024-10-31
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-08-03
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 2024-08-09
D · Potential for more than minimal harm
2024-08-03
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-08-09
J · Immediate jeopardy
2024-07-18
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 2024-07-19
J · Immediate jeopardy
2024-07-18
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-07-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-04-29
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 2024-05-24
E · Potential for more than minimal harm
2023-08-30
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 2023-09-26
D · Potential for more than minimal harm
2023-08-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-30
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 2023-09-26
D · Potential for more than minimal harm
2023-08-30
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-03-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-15
E · Potential for more than minimal harm
2022-06-09
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 2022-07-01
E · Potential for more than minimal harm
2022-06-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-06-09
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 2022-07-01
E · Potential for more than minimal harm
2022-06-09
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-06-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-06-09
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 2022-07-01
Penalties and ownership
What sits behind the stars
$10,293
2024-07-18
Fine
Fine · fine $10,293
Fine
Ownership
Caraday Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
Cara Capital LLC
5% Or Greater Indirect Ownership Interest · Organization
Caraday Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Choi, Maryann
5% Or Greater Indirect Ownership Interest · Individual
Choi, Robert
5% Or Greater Indirect Ownership Interest · Individual
Daybach Investments, LP
5% Or Greater Indirect Ownership Interest · Organization
E&R Cunningham Investments LP
5% Or Greater Indirect Ownership Interest · Organization
Granite Round Rock, LLC
5% Or Greater Mortgage Interest · Organization
Moore, Gregory
Operational/Managerial Control · Individual
Moore, Gregory
Corporate Officer · Individual
O'donoghue-Stallard, Maire
5% Or Greater Indirect Ownership Interest · Individual
Stallard, Thomas
5% Or Greater Indirect Ownership Interest · Individual
Tala Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Wood, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Ysmlc Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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San Gabriel Rehabilitation and Care Center
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#2
Hearthstone Nursing And Rehabilitation
Round Rock, TX
3-star overall rating with 3-star inspections with $152,617 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Park Valley Inn Health Center
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2-star overall rating with 1-star inspections with abuse icon flag with $97,032 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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