Cycle 1
Health 2025-03-28 · Fire 2025-03-28
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Wharton, TX
Wharton Nursing and Rehabilitation Center
3-star overall rating with 3-star inspections with $19,725 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1220 Sunny Lane, Wharton, TX
(979) 532-5020
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
83
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
1994-07-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 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
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.85
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.48
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.15
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,223
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
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
3.71
Baseline 6.66% · Performance 6.73% · Measure score 3.71 · Achievement 3.71 · Improvement 0
Total nurse turnover
3.52
Baseline 65.17% · Performance 49.30% · Measure score 3.52 · Achievement 3.52 · Improvement 3.44
Adjusted total nurse staffing
1.01
Baseline 3.19 hours · Performance 3.36 hours · Measure score 1.01 · Achievement 1.01 · Improvement 0.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.04% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 13.79% · Lower 95% interval 7.65% |
| Discharge to community | 38.95% |
50.57%
11.6 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 28.89% · Lower 95% interval 27.49% |
| Medicare spending per beneficiary | 1.52 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 14 · Denominator 21 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 9 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 1 · Denominator 36 · Adjusted rate 1.82% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 92 |
| Staff flu vaccination coverage | 65.56% |
42%
23.6 pts better
|
Numerator 99 · Denominator 151 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 12 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · 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 | 1.3% |
3.3%
2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.3% · Q4 2.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
3.3%
1.6 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 2.7% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
18.9%
0.4 pts better
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 17.8% · Q3 17.3% · Q4 20.8% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
10.8%
6.9 pts worse
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 16.9% · Q3 16.9% · Q4 17.2% · 4Q avg 17.7% · 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 | 3.3% |
15.4%
12.1 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 3.1% · Q4 5.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
16.1%
10.1 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.5% · Q3 7.6% · Q4 4.9% · 4Q avg 6.0% · 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 | 1.9% |
15.0%
13.1 pts better
|
19.8%
17.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 1.2% · Q4 1.3% · 4Q avg 1.9% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.2%
1.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.6% · Q3 3.2% · Q4 1.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
89.7%
2.6 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 88.7% · Q3 97.9% · Q4 96.7% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
12.0%
5.6 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 9.1% · Expected 15.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
88.0%
2.9 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
25.9%
1.6 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 31.8% · Expected 31.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-19 · Fire 2024-01-19
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
5 health deficiencies
Top issue: Infection Control (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
2025-03-28
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-04-16
F · Potential for more than minimal harm
2024-01-19
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-02
E · Potential for more than minimal harm
2025-03-28
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 2025-04-01
D · Potential for more than minimal harm
2025-03-28
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 2025-04-01
D · Potential for more than minimal harm
2025-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-01
J · Immediate jeopardy
2025-03-07
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 2024-12-06
G · Actual harm
2025-03-07
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 2025-03-11
D · Potential for more than minimal harm
2024-07-02
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 2024-07-26
E · Potential for more than minimal harm
2024-01-19
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 2024-01-26
D · Potential for more than minimal harm
2024-01-19
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-08-16
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 2023-08-22
D · Potential for more than minimal harm
2023-08-16
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-21
E · Potential for more than minimal harm
2022-10-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-18
Penalties and ownership
What sits behind the stars
$11,444
2026-02-06
Fine
Fine · fine $11,444
Fine
$8,281
2025-03-07
Fine
Fine · fine $8,281
Fine
Ownership
Citizens Medical Center County Of Victoria
5% Or Greater Direct Ownership Interest · Organization
Citizens Medical Center County Of Victoria
Operational/Managerial Control · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Dozier, Marshelda
Operational/Managerial Control · Individual
Olson, Michael
Corporate Officer · Individual
Regency Ihs Of Wharton LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Nearby options
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Paradigm at the Creek
Wharton, TX
1-star overall rating with 1-star inspections with $48,176 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Paradigm at the Prairies
El Campo, TX
2-star overall rating with 2-star inspections with abuse icon flag with $49,277 in total fines with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
SPJST Rest Home No 2
Needville, TX
5-star overall rating with 5-star inspections with $12,649 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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