Cycle 1
Health 2025-01-31 · Fire 2025-01-31
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
Capstone Healthcare Estates at Veterans Memorial
3-star overall rating with 3-star inspections with $21,645 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1424 Fallbrook Drive, Houston, TX
(346) 754-5070
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-06-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.39
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,741
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.31
Baseline 21.54% · Performance 20.82% · Measure score 1.31 · Achievement 1.31 · Improvement 1.09
Healthcare-associated infections
0
Baseline 8.27% · Performance 8.70% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.75
Performance 44.25% · Measure score 4.75 · Achievement 4.75 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.01
Baseline 3.98 hours · Performance 3.93 hours · Measure score 3.01 · Achievement 3.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.12% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 14% · Lower 95% interval 7.9% |
| Discharge to community | 44.33% |
50.57%
6.2 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 32.69% · Lower 95% interval 30.33% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 66 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 63.89% |
53.69%
10.2 pts better
|
Numerator 23 · Denominator 36 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 18 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 66 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.7% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 17.39% · Lower 95% interval 5.4% |
| Staff COVID-19 vaccination coverage | 10.81% |
8.2%
2.6 pts better
|
Numerator 12 · Denominator 111 |
| Staff flu vaccination coverage | 21.79% |
42%
20.2 pts worse
|
Numerator 34 · Denominator 156 |
| Discharge function score | 52.78% |
56.45%
3.7 pts worse
|
Numerator 19 · Denominator 36 |
| Transfer of health information to provider | 96.97% |
95.95%
1 pts better
|
Numerator 32 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.86% |
25.2%
22.3 pts worse
|
Numerator 1 · Denominator 35 |
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 2.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.3%
1.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 1.2% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
18.9%
5.9 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 24.7% · Q3 23.7% · Q4 25.0% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
10.8%
0.1 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 13.1% · Q3 10.3% · Q4 10.0% · 4Q avg 10.7% · 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 | 18.3% |
15.4%
2.9 pts worse
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 22.2% · Q3 33.5% · Q4 13.7% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
16.1%
5.7 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 23.3% · Q3 33.3% · Q4 25.4% · 4Q avg 21.8% · 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 | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
15.0%
4 pts worse
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 17.0% · Q3 12.2% · Q4 23.8% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
4.2%
1.9 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.0% · Q3 4.9% · Q4 3.4% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
89.7%
10 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
12.0%
2.9 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 10.7% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
25.9%
3 pts better
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 25.0% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-08 · Fire 2023-12-08
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
6 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-31
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-03-12
F · Potential for more than minimal harm
2023-12-08
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-01-04
F · Potential for more than minimal harm
2023-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-04
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-31
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 2025-10-08
G · Actual harm
2025-10-31
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-11-03
E · Potential for more than minimal harm
2025-10-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-11-03
D · Potential for more than minimal harm
2025-04-15
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 2025-05-12
F · Potential for more than minimal harm
2025-01-31
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 2025-03-10
D · Potential for more than minimal harm
2025-01-31
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 2025-03-10
D · Potential for more than minimal harm
2025-01-03
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 2025-01-31
E · Potential for more than minimal harm
2023-12-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-08
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-09-27
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 2023-10-23
D · Potential for more than minimal harm
2023-04-26
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 2023-05-20
E · Potential for more than minimal harm
2022-09-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-09-26
E · Potential for more than minimal harm
2022-09-09
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 2022-09-26
E · Potential for more than minimal harm
2022-09-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-26
D · Potential for more than minimal harm
2022-09-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-26
Penalties and ownership
What sits behind the stars
$21,645
2025-10-31
Fine
Fine · fine $21,645
Fine
Ownership
Nearby options
Other facilities in reach
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Houston, TX
2-star overall rating with 2-star inspections with abuse icon flag with $109,995 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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Houston, TX
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Ashford Gardens
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4-star overall rating with 3-star inspections with $11,009 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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