C71

THE WESLEYAN SKILLED NURSING AND REHABILITATION

Grade C 71/100 composite score

Non profit - Corporation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
4/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

142

Ownership

Non profit - Corporation

Total Fines

$8,281

Last Survey

N/A

4011 WILLIAMS DR, GEORGETOWN, TX 78628
5128682700

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.45h
LPN
0.99h
CNA
2.57h
Total
4.00h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

SOUTH LIMESTONE HOSPITAL DISTRICT

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2017

CHANEY, DENA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2025

DONOHUE, LORENA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2025

STRONG, TYLER

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2025

PRICE, LARRY

IndividualCORPORATE DIRECTORSince Apr 2017

Penalties & Fines (1)

$8,281total fines
DateTypeDescriptionAmount
Mar 17, 2025Fine$8,281

Health Inspection Deficiencies (16)

April 30, 2025Health8 deficiencies
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected May 30, 2025
0558EMinimal harm, Pattern

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected May 30, 2025
0604DMinimal harm, Isolated

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 16, 2025
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected May 27, 2025
0688DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected May 30, 2025
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected May 23, 2025
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected May 1, 2025
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected May 30, 2025
March 17, 2025Health2 deficiencies1 severe
0684JImmediate jeopardy, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 23, 2025
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 12, 2025
March 3, 2025Health2 deficiencies
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Feb 7, 2025
0603DMinimal harm, Isolated

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Feb 7, 2025
February 29, 2024Health3 deficiencies
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Mar 1, 2024
0657EMinimal harm, Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 21, 2024
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Mar 1, 2024
December 9, 2022Health1 deficiency
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 13, 2023

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Frequently Asked Questions

What is the CareGrader rating for THE WESLEYAN SKILLED NURSING AND REHABILITATION?

THE WESLEYAN SKILLED NURSING AND REHABILITATION in GEORGETOWN, Texas has a CareGrader grade of C (Average), with a composite score of 71 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for THE WESLEYAN SKILLED NURSING AND REHABILITATION?

THE WESLEYAN SKILLED NURSING AND REHABILITATION has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does THE WESLEYAN SKILLED NURSING AND REHABILITATION have?

THE WESLEYAN SKILLED NURSING AND REHABILITATION has 16 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has THE WESLEYAN SKILLED NURSING AND REHABILITATION been fined?

Yes. THE WESLEYAN SKILLED NURSING AND REHABILITATION has $8,281 in total fines from CMS enforcement actions across 1 penalty.

How many beds does THE WESLEYAN SKILLED NURSING AND REHABILITATION have?

THE WESLEYAN SKILLED NURSING AND REHABILITATION has 142 certified beds with approximately 75 current residents (53% occupancy). The facility is located at 4011 WILLIAMS DR, GEORGETOWN, Texas 78628. It is a non profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.