Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasAbove 87% of peers1,167 rated homes · average 2.8★
- United StatesAbove 80% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point4★+1.2 vs TX avg
- StaffingCan add or remove a star4★+1.9 vs TX avg
- Quality measuresCan add or remove a star5★+1.2 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles4★Above 67% of peersTX avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 88% of peersTX avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 68% of peersTX avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.15hrsAbove only 34% of peersTX avg3.40Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.50hrsAbove 73% of peersTX avg0.44Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better47%Above 60% of peersTX avg51%RN turnover33%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$10,135Above 63% of peersTX avg$55,368Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthMay 2022 – Aug 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Aug 29, 2024Cycle 1worst E · no actual harm
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 23, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 23, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Sep 23, 2024
- F583Keep residents' personal and medical records private and confidential.Resident RightsE · patternCorrected Sep 23, 2024
May 6, 2024Cycle 2worst G · actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected May 7, 2024
Oct 19, 2023Cycle 3worst D · no actual harm$10,135
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Nov 3, 2023
Oct 5, 2023Cycle 3worst J · immediate jeopardy$10,135
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Oct 6, 2023
Jul 7, 2023Cycle 2worst E · no actual harm
- F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Aug 7, 2023
- F656Develop 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 PlanningE · patternCorrected Aug 7, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 7, 2023
May 4, 2022Cycle 3worst E · no actual harm
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected May 20, 2022
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected May 20, 2022
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected May 20, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected May 20, 2022
- F761Ensure 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 ServiceD · isolatedCorrected May 20, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 20, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.15hrs
- Registered nursesRN hours only0.50hrs
- Licensed practical nursesLPN hours0.58hrs
- Nurse aidesCNA hours2.07hrs
- Weekend nursingAll staff on Saturdays and Sundays2.56hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better47%Above 60% of peersTX avg 51%
- RN turnoverRegistered nurses only33%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy74 certified beds · ~46 residents a day62%Above only 39% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $10,135In fines
- 1Fine
- 0Payment denials
- $55,368TX avg in fines
Actions on record
- Oct 5, 2023Civil money penalty$10,135
Ownership
As filed with CMSStructure
- Ownership type
- Government - City/county
- Chain
- Creative Solutions in Healthcare149 facilities in the chain2.6★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
- West Wharton County Hospital District
- Bertram I Enterprises, LLC
- Gary Blake
- Malisa Blake
- Linda Huggins
- Zachary Willig
- Johnny Thompson
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 676117 · 540 E STATE HWY 29, BERTRAM, TX, 78605.
- Percentiles compare this facility with every rated nursing home in Texas and Burnet County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
