Cycle 1
Health 2024-10-16 · Fire 2024-10-16
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
El Paso, TX
White Acres Wellness & Rehabilitation
2-star overall rating with 3-star inspections with $4,475 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
7304 Good Samaritan Court, El Paso, TX
(915) 581-4683
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
74
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
1992-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 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
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,495
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9895
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.54
Baseline 17.71% · Performance 19.79% · Measure score 3.54 · Achievement 3.54 · Improvement 0
Healthcare-associated infections
0.80
Baseline 7.01% · Performance 7.60% · Measure score 0.80 · Achievement 0.80 · Improvement 0
Total nurse turnover
9.24
Baseline 24.44% · Performance 25.93% · Measure score 9.24 · Achievement 9.24 · Improvement 0
Adjusted total nurse staffing
0.81
Baseline 3.46 hours · Performance 3.31 hours · Measure score 0.81 · Achievement 0.81 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.93% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 11.97% · Lower 95% interval 7.89% |
| Discharge to community | 48.28% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 111 · Observed rate 44.14% · Lower 95% interval 39.45% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.88% |
95.27%
1.4 pts worse
|
Numerator 46 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 55.26% |
53.69%
1.6 pts better
|
Numerator 21 · Denominator 38 |
| Discharge mobility score | 55.26% |
50.94%
4.3 pts better
|
Numerator 21 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 7.89% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 1.92% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 104 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 144 · Denominator 144 |
| Discharge function score | 34.21% |
56.45%
22.2 pts worse
|
Numerator 13 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 92.31% |
96.28%
4 pts worse
|
Numerator 36 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 11 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
97.1%
1.1 pts worse
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 95.0% · Q3 95.0% · Q4 98.0% · 4Q avg 96.0% |
| 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 | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.5% · Q3 2.5% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 2.7% |
3.3%
0.6 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 0.0% · Q4 4.9% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
18.9%
0.8 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 21.6% · Q3 21.6% · Q4 16.7% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
10.8%
5 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 20.0% · Q4 17.6% · 4Q avg 15.8% · 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 | 3.9% |
15.4%
11.5 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
16.1%
5.2 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 9.1% · Q3 13.3% · Q4 9.1% · 4Q avg 10.9% · 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 | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.3% |
15.0%
13.3 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 31.3% · Q3 16.0% · Q4 22.2% · 4Q avg 28.3% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.2%
0.8 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.1% · Q3 1.7% · Q4 4.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
89.7%
9.1 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.5% · Q3 100.0% · Q4 98.2% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.2% |
12.0%
5.2 pts worse
|
12.0%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 16.2% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
88.0%
10.5 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| 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 22.1% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-07-08 · Fire 2022-07-08
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
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
2024-10-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-25
D · Potential for more than minimal harm
2023-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-14
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-08-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-08-18
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 2025-08-19
D · Potential for more than minimal harm
2025-08-18
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 2025-08-19
E · Potential for more than minimal harm
2025-03-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-01-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-01-09
F · Potential for more than minimal harm
2024-10-16
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 2024-11-15
E · Potential for more than minimal harm
2024-10-16
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 2024-11-15
E · Potential for more than minimal harm
2024-10-16
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-16
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-16
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 2024-11-15
D · Potential for more than minimal harm
2024-09-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-27
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 2024-10-14
D · Potential for more than minimal harm
2024-03-15
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 2024-04-18
D · Potential for more than minimal harm
2024-03-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-15
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 2024-04-18
D · Potential for more than minimal harm
2024-03-15
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 2024-04-18
D · Potential for more than minimal harm
2024-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-18
F · Potential for more than minimal harm
2023-08-24
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 2023-09-21
E · Potential for more than minimal harm
2023-08-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-08-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-24
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 2023-09-21
D · Potential for more than minimal harm
2023-08-24
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
2023-08-24
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 2023-09-21
D · Potential for more than minimal harm
2023-08-24
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-21
D · Potential for more than minimal harm
2022-07-08
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-08-12
Penalties and ownership
What sits behind the stars
$4,475
2023-08-24
Fine
Fine · fine $4,475
Fine
Ownership
Frio Hospital District
5% Or Greater Direct Ownership Interest · Organization
7304 Good Samaritan Ct Tx, LLC
5% Or Greater Mortgage Interest · Organization
Garetz, David
Operational/Managerial Control · Individual
Gibraltar Trust
5% Or Greater Mortgage Interest · Organization
Hazboun, Ramsey
Operational/Managerial Control · Individual
Jse 97 Holdings, LLC
5% Or Greater Mortgage Interest · Organization
Montgomery Sky Trust
5% Or Greater Mortgage Interest · Organization
Pinyon Realty, LLC
5% Or Greater Mortgage Interest · Organization
Ruff, Michael
Corporate Officer · Individual
Strohmyer, Brinton
Operational/Managerial Control · Individual
White Acres Wellness & Rehabilitation, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
The Bartlett Skilled Nursing And Assisted Living
El Paso, TX
1-star overall rating with 2-star inspections with abuse icon flag with $33,150 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Franklin Heights Nursing & Rehabilitation
El Paso, TX
2-star overall rating with 1-star inspections with $191,503 in total fines with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Avir at El Paso
El Paso, TX
1-star overall rating with 1-star inspections with $199,581 in total fines with 15 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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