Cycle 1
Health 2025-12-11 · Fire 2025-12-11
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Houston, TX
Bayou Manor
5-star overall rating with 5-star inspections with $57,184 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4141 S Braeswood Blvd, Houston, TX
(713) 666-2651
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-05-18
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.85
Registered nurse staffing
LPN hours / resident day
1.10
Licensed practical nurse staffing
Aide hours / resident day
4.10
Nurse aide staffing
Weekend hours
5.65
Weekend nurse staffing
RN turnover
20%
Annual RN turnover
Total nurse turnover
24%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
97.1%
2 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.0% |
97.9%
12.9 pts worse
|
95.5%
10.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.3%
1.6 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
18.9%
8.5 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 28.9% |
10.8%
18.1 pts worse
|
16.7%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
16.1%
12.5 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.6% |
0.5%
7.1 pts worse
|
1.0%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.2% |
15.0%
1.8 pts better
|
19.8%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 11.1% |
4.2%
6.9 pts worse
|
5.1%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.8% |
89.7%
2.9 pts worse
|
81.7%
5.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.7% |
12.0%
8.3 pts better
|
12.0%
8.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.2% |
88.0%
25.8 pts worse
|
79.7%
17.5 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
25.9%
1 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-15 · Fire 2023-06-15
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-15
E · Potential for more than minimal harm
2024-08-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-16
E · Potential for more than minimal harm
2023-06-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-07-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
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 2026-01-15
E · Potential for more than minimal harm
2025-11-10
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 2025-12-15
D · Potential for more than minimal harm
2024-08-15
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 2024-10-01
E · Potential for more than minimal harm
2023-06-15
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 2023-07-15
E · Potential for more than minimal harm
2023-06-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-15
E · Potential for more than minimal harm
2023-06-15
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 2023-07-15
Penalties and ownership
What sits behind the stars
$4,545
2023-08-14
Fine
Fine · fine $4,545
Fine
$4,545
2023-08-07
Fine
Fine · fine $4,545
Fine
$13,635
2023-07-17
Fine
Fine · fine $13,635
Fine
$4,545
2023-06-26
Fine
Fine · fine $4,545
Fine
$4,545
2023-06-20
Fine
Fine · fine $4,545
Fine
$4,196
2023-06-12
Fine
Fine · fine $4,196
Fine
$3,882
2023-06-05
Fine
Fine · fine $3,882
Fine
$3,529
2023-05-30
Fine
Fine · fine $3,529
Fine
$3,176
2023-05-23
Fine
Fine · fine $3,176
Fine
$2,823
2023-05-15
Fine
Fine · fine $2,823
Fine
$2,470
2023-05-08
Fine
Fine · fine $2,470
Fine
$5,293
2023-04-17
Fine
Fine · fine $5,293
Fine
Ownership
Braly, Locke
Corporate Officer · Individual
Cummings, Michael
Operational/Managerial Control · Individual
Darden, Sharon
Corporate Director · Individual
Elledge, David
Corporate Officer · Individual
Gans, Andy
Corporate Director · Individual
Greene, Marcy
Corporate Director · Individual
Hartman, John
Corporate Director · Individual
Hudson, John
Corporate Director · Individual
Jo, John
Corporate Director · Individual
Kinsey, Deidre
Operational/Managerial Control · Individual
Kinsey, Deidre
Corporate Officer · Individual
Leathers, Richard
Corporate Director · Individual
Lemen, John
Corporate Director · Individual
Mcphail, Suzanne
Corporate Director · Individual
Nunn, Richard
Corporate Officer · Individual
Redden, Kathleen
Corporate Director · Individual
Rouchon, Omar
Corporate Director · Individual
Wennenweser, Jeanette
Corporate Director · Individual
Nearby options
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3-star overall rating with 3-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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#3
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