Cycle 1
Health 2025-06-05 · Fire 2025-06-05
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Temple, TX
Wellington Rehabilitation and Healthcare
1-star overall rating with 2-star inspections with $31,752 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1802 S 31St, Temple, TX
(254) 778-4231
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
67
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1986-02-14
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
0.25
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.99
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.52
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
91%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
80%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,236
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.73
Performance 21.09% · Measure score 0.73 · Achievement 0.73 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.11% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 58.82% · Performance 75.81% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.19
Baseline 2.77 hours · Performance 3.58 hours · Measure score 2.19 · Achievement 1.78 · Improvement 2.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 46 · Observed rate 13.04% · Lower 95% interval 7.27% |
| Discharge to community | 57.21% |
50.57%
6.6 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 53.85% · Lower 95% interval 40.25% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 79.49% |
95.27%
15.8 pts worse
|
Numerator 31 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 11 · Denominator 22 |
| Discharge mobility score | 31.82% |
50.94%
19.1 pts worse
|
Numerator 7 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.11% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 17.09% |
42%
24.9 pts worse
|
Numerator 27 · Denominator 158 |
| Discharge function score | 31.82% |
56.45%
24.6 pts worse
|
Numerator 7 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.7% |
25.2%
16.5 pts worse
|
Numerator 2 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
97.1%
0.5 pts worse
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 96.2% · Q3 96.2% · Q4 96.3% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.5% |
97.9%
3.4 pts worse
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.3%
0.9 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 3.8% · Q4 1.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
2.7%
3.8 pts worse
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.2% · Q3 7.7% · Q4 6.5% · 4Q avg 6.5% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
3.3%
0.1 pts worse
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.2% · Q3 4.4% · Q4 2.2% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.3% |
18.9%
7.6 pts better
|
19.6%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 12.0% · Q3 12.8% · Q4 10.4% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
10.8%
2.8 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.8% · Q3 12.5% · Q4 4.5% · 4Q avg 8.0% · 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 | 66.2% |
15.4%
50.8 pts worse
|
16.3%
49.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 66.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.9% |
16.1%
18.8 pts worse
|
14.9%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.8% · Q2 32.6% · Q3 35.7% · Q4 34.9% · 4Q avg 34.9% · 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 | 2.0% |
0.8%
1.2 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.0% · Q3 0.0% · Q4 1.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
15.0%
13.4 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.7% · Q2 22.9% · Q3 22.7% · Q4 23.8% · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.2%
2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.1% · Q4 4.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
89.7%
6.1 pts worse
|
81.7%
1.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 81.8% · Q3 84.9% · Q4 83.5% · 4Q avg 83.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
12.0%
2 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 16.1% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.1% · Q4 1.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.0% |
88.0%
10 pts worse
|
79.7%
1.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
25.9%
5.7 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 22.6% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-05
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-05
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 2025-07-18
F · Potential for more than minimal harm
2024-04-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-01
F · Potential for more than minimal harm
2024-04-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-06
E · Potential for more than minimal harm
2024-04-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-01
E · Potential for more than minimal harm
2024-04-25
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 2025-03-06
E · Potential for more than minimal harm
2024-04-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-06
E · Potential for more than minimal harm
2024-04-25
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 2025-03-06
E · Potential for more than minimal harm
2024-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-01
E · Potential for more than minimal harm
2024-04-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-06
D · Potential for more than minimal harm
2024-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-01
E · Potential for more than minimal harm
2023-03-02
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 2023-06-20
C · Minimal harm
2023-03-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-27
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 2025-08-28
J · Immediate jeopardy
2025-06-24
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 2025-06-25
J · Immediate jeopardy
2025-06-24
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 2025-06-25
D · Potential for more than minimal harm
2025-06-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-06
J · Immediate jeopardy
2024-11-21
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 2024-09-27
E · Potential for more than minimal harm
2024-07-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-16
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 2024-08-06
D · Potential for more than minimal harm
2024-05-08
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 2024-06-03
E · Potential for more than minimal harm
2024-04-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-25
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 2024-05-24
E · Potential for more than minimal harm
2024-04-25
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 2024-05-30
E · Potential for more than minimal harm
2024-04-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-04-25
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 2024-05-29
D · Potential for more than minimal harm
2024-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-29
E · Potential for more than minimal harm
2023-09-19
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-19
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-05-22
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 2023-06-16
E · Potential for more than minimal harm
2023-03-02
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 2023-03-31
E · Potential for more than minimal harm
2023-03-02
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 2023-03-31
E · Potential for more than minimal harm
2023-03-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-02
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 2023-03-31
D · Potential for more than minimal harm
2023-03-02
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 2023-03-31
D · Potential for more than minimal harm
2023-03-02
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 2023-03-31
D · Potential for more than minimal harm
2023-03-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
$22,925
2025-06-24
Fine
Fine · fine $22,925
Fine
$8,827
2024-11-21
Fine
Fine · fine $8,827
Fine
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Harris, Martin
Operational/Managerial Control · Individual
Hoffman, William
Corporate Officer · Individual
Joiner, Stephen
Corporate Director · Individual
Lasater, Emmett
Corporate Director · Individual
Moylan, Missy
Corporate Director · Individual
Squiers, Noble
Corporate Director · Individual
Stewart, Nancy
Corporate Director · Individual
Tucker, Jacquelyn
Corporate Director · Individual
Wellington Healthcare, Inc.
Operational/Managerial Control · Organization
Wright, Laban
Operational/Managerial Control · Individual
Wright, Laban
Corporate Officer · Individual
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