Cycle 1
Health 2025-05-15 · Fire 2025-05-15
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Richmond, TX
Cambridge Health And Rehabilitation Center
3-star overall rating with 2-star inspections with $68,342 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1106 Golfview, Richmond, TX
(281) 344-9191
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
158
Certified beds
Average residents
119
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2001-09-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.58
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
1.90
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,708
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.06
Baseline 21.93% · Performance 19.70% · Measure score 4.06 · Achievement 3.74 · Improvement 4.06
Healthcare-associated infections
0
Baseline 6.81% · Performance 7.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.66
Baseline 54.55% · Performance 52.81% · Measure score 2.66 · Achievement 2.66 · Improvement 0.08
Adjusted total nurse staffing
1.05
Baseline 3.12 hours · Performance 3.38 hours · Measure score 1.05 · Achievement 1.05 · Improvement 0.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 116 · Observed rate 12.07% · Lower 95% interval 7.85% |
| Discharge to community | 58.87% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 50.48% · Lower 95% interval 49.87% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 75.81% |
95.27%
19.5 pts worse
|
Numerator 47 · Denominator 62 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 62 |
| Discharge self-care score | 28.57% |
53.69%
25.1 pts worse
|
Numerator 12 · Denominator 42 |
| Discharge mobility score | 47.62% |
50.94%
3.3 pts worse
|
Numerator 20 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 62 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 11.54% · Lower 95% interval 4.71% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 152 |
| Staff flu vaccination coverage | 13.02% |
42%
29 pts worse
|
Numerator 28 · Denominator 215 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 21 · Denominator 42 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 18 · Denominator 20 |
| Transfer of health information to patient | 86.21% |
96.28%
10.1 pts worse
|
Numerator 25 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 12.2% |
25.2%
13 pts worse
|
Numerator 5 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
97.1%
1.8 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
97.9%
3.1 pts worse
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.3%
2.7 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
2.7%
3.9 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 7.3% · Q3 2.4% · Q4 0.0% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
3.3%
0.1 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.9% · Q3 2.4% · Q4 3.6% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
18.9%
7.2 pts better
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 13.9% · Q3 10.8% · Q4 9.5% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
10.8%
4.6 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.3% · Q3 6.2% · Q4 6.2% · 4Q avg 6.2% · 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 | 7.4% |
15.4%
8 pts better
|
16.3%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.2% · Q3 3.2% · Q4 12.2% · 4Q avg 7.4% · 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 19.0% · Q2 9.5% · Q3 6.0% · Q4 10.0% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 10.0% |
15.0%
5 pts better
|
19.8%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 14.1% · Q3 2.0% · Q4 8.6% · 4Q avg 10.0% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.2%
0.3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.2% · Q3 4.6% · Q4 2.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
89.7%
4.2 pts worse
|
81.7%
3.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 82.9% · Q3 91.0% · Q4 85.5% · 4Q avg 85.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
12.0%
3.3 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 10.5% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.4% |
88.0%
15.6 pts worse
|
79.7%
7.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.7% |
25.9%
4.8 pts worse
|
23.9%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.7% · Observed 35.1% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-01-24 · Fire 2023-01-24
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-15
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-06-06
E · Potential for more than minimal harm
2024-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-03-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-14
E · Potential for more than minimal harm
2023-01-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
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 2026-01-21
D · Potential for more than minimal harm
2025-05-15
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 2025-05-23
D · Potential for more than minimal harm
2025-05-15
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 2025-05-23
D · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-09
G · Actual harm
2025-01-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-11
D · Potential for more than minimal harm
2025-01-10
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 2025-01-01
D · Potential for more than minimal harm
2024-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-14
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 2024-03-22
D · Potential for more than minimal harm
2024-03-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-14
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 2024-03-22
K · Immediate jeopardy
2024-02-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-08
K · Immediate jeopardy
2023-09-29
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-09-30
J · Immediate jeopardy
2023-09-29
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-09-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-09-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-09-29
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 2023-09-30
D · Potential for more than minimal harm
2023-09-29
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 2023-09-30
J · Immediate jeopardy
2023-08-30
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 2023-09-06
D · Potential for more than minimal harm
2023-01-24
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 2023-02-07
Penalties and ownership
What sits behind the stars
$18,821
2025-01-10
Fine
Fine · fine $18,821
Fine
$16,448
2024-02-01
Fine
Fine · fine $16,448
Fine
$13,397
2023-08-30
Fine
Fine · fine $13,397
Fine
$19,676
2023-08-30
Fine
Fine · fine $19,676
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Eapen, Sheila
Operational/Managerial Control · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Richmond Senior Services, Inc.
Operational/Managerial Control · Organization
Solipuram, Arun Kumar
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Richmond Health Care Center
Richmond, TX
4-star overall rating with 4-star inspections with $78,036 in total fines with 1 recent health deficiencies
#2
Oak Bend Medical Center
Richmond, TX
5-star overall rating with 5-star inspections with $17,560 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Rosenberg Health & Rehabilitation Center
Rosenberg, TX
1-star overall rating with 1-star inspections with Special Focus status with $142,384 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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