Cycle 1
Health 2025-06-19 · Fire 2025-06-19
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Houston, TX
Brookdale Galleria
1-star overall rating with 2-star inspections with $62,489 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2929 Post Oak Blvd, Houston, TX
(713) 993-9999
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
56
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
2000-08-03
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 4 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
1.01
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.40
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.93
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,122
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.47% · Performance 22.09% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.33
Baseline 6.79% · Performance 6.54% · Measure score 4.33 · Achievement 4.33 · Improvement 0.90
Total nurse turnover
0.52
Baseline 60.00% · Performance 61.54% · Measure score 0.52 · Achievement 0.52 · Improvement 0
Adjusted total nurse staffing
5.02
Baseline 5.07 hours · Performance 4.51 hours · Measure score 5.02 · Achievement 5.02 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.75% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 286 · Observed rate 12.94% · Lower 95% interval 9.4% |
| Discharge to community | 63.35% |
50.57%
12.8 pts better
|
Better than the National Rate · Eligible stays 303 · Observed rate 56.44% · Lower 95% interval 55.55% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.47% |
95.27%
1.2 pts better
|
Numerator 164 · Denominator 170 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 170 |
| Discharge self-care score | 69.44% |
53.69%
15.8 pts better
|
Numerator 75 · Denominator 108 |
| Discharge mobility score | 62.96% |
50.94%
12 pts better
|
Numerator 68 · Denominator 108 |
| Pressure ulcers or injuries, new or worsened | 3.53% |
2.29%
1.2 pts worse
|
Numerator 6 · Denominator 170 · Adjusted rate 2.87% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 200 · Observed rate 6% · Lower 95% interval 4.44% |
| Staff COVID-19 vaccination coverage | 2.91% |
8.2%
5.3 pts worse
|
Numerator 3 · Denominator 103 |
| Staff flu vaccination coverage | 24.68% |
42%
17.3 pts worse
|
Numerator 19 · Denominator 77 |
| Discharge function score | 71.3% |
56.45%
14.8 pts better
|
Numerator 77 · Denominator 108 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | 99.04% |
96.28%
2.8 pts better
|
Numerator 103 · Denominator 104 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 79 |
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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who lose too much weight | 8.7% |
3.3%
5.4 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
18.9%
10.2 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.7% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 40.0% |
16.1%
23.9 pts worse
|
14.9%
25.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 9.0% |
0.5%
8.5 pts worse
|
1.0%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with pressure ulcers | 18.5% |
4.2%
14.3 pts worse
|
5.1%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
89.7%
4.2 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.9% · Q2 92.6% · Q3 97.0% · Q4 100.0% · 4Q avg 93.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
12.0%
4.3 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.1% |
88.0%
4.1 pts better
|
79.7%
12.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
25.9%
0.8 pts better
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 26.2% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-24 · Fire 2024-04-24
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-02-23 · Fire 2023-02-23
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-06-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-27
C · Minimal harm
2025-06-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-27
F · Potential for more than minimal harm
2024-04-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-24
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 2024-05-15
F · Potential for more than minimal harm
2024-04-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-15
E · Potential for more than minimal harm
2023-02-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-02-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-25
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 2025-11-26
D · Potential for more than minimal harm
2025-11-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-25
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 2025-11-26
C · Minimal harm
2025-11-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-18
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 2025-11-19
E · Potential for more than minimal harm
2025-06-19
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 2025-06-20
G · Actual harm
2024-12-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-04-24
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-24
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 2024-05-15
D · Potential for more than minimal harm
2024-04-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-15
K · Immediate jeopardy
2024-04-04
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 2024-04-05
K · Immediate jeopardy
2024-04-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-24
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 2024-02-16
D · Potential for more than minimal harm
2024-01-24
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 2024-02-16
H · Actual harm
2023-12-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-12-11
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 2023-12-20
D · Potential for more than minimal harm
2023-12-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-02-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-23
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 2023-03-10
D · Potential for more than minimal harm
2023-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
$10,033
2024-12-17
Fine
Fine · fine $10,033
Fine
$40,203
2024-04-04
Fine
Fine · fine $40,203
Fine
$12,253
2023-12-11
Fine
Fine · fine $12,253
Fine
Ownership
Sh 2019 Opcp Holdco I, LLC
5% Or Greater Direct Ownership Interest · Organization
Cheng, Patrick
Corporate Officer · Individual
Gic (Realty) Private Limited
5% Or Greater Indirect Ownership Interest · Organization
Hcp S-H 2015 Member Inc
5% Or Greater Indirect Ownership Interest · Organization
Hcp Senior Housing Properties, LLC
5% Or Greater Indirect Ownership Interest · Organization
Hcp Ventures Ii Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Hcp Ventures Ii Partner LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Properties Inc
5% Or Greater Indirect Ownership Interest · Organization
Henry, Andrea
W-2 Managing Employee · Individual
Johnston, Shawn
Corporate Officer · Individual
Leskowicz, Joanne
Corporate Officer · Individual
Na-Re Investment Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Russo, Frank
Corporate Officer · Individual
S-H Thirty-Five Propco Ventures LLC
5% Or Greater Indirect Ownership Interest · Organization
S-H Thirty-Five Properties, LLC
5% Or Greater Indirect Ownership Interest · Organization
S-H Twenty-One Propco Ventures LLC
5% Or Greater Indirect Ownership Interest · Organization
Sage Senior Living LLC
5% Or Greater Indirect Ownership Interest · Organization
Sh 2019 Opco Trs I LLC
5% Or Greater Indirect Ownership Interest · Organization
Sh 2019 Reit I LLC
5% Or Greater Indirect Ownership Interest · Organization
Sh 2019 Ventures LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
The Hallmark
Houston, TX
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
Woodway Nursing & Rehab
Houston, TX
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $271,160 in total fines with 34 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Vosswood Nursing Center
Houston, TX
4-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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