Cycle 1
Health 2025-10-01 · Fire 2025-10-01
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Missouri City, TX
Chelsea Gardens
4-star overall rating with 4-star inspections with $56,103 in total fines with 3 fire-safety deficiencies in the latest cycle
4422 Riverstone Blvd, Missouri City, TX
(281) 499-5040
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-03-12
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
0.72
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
60%
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
9,689
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.75
Baseline 23.63% · Performance 20.17% · Measure score 4.75 · Achievement 2.72 · Improvement 4.75
Healthcare-associated infections
2.28
Baseline 8.65% · Performance 7.63% · Measure score 2.28 · Achievement 0.68 · Improvement 2.28
Total nurse turnover
0
Performance 69.64% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.12
Baseline 4.22 hours · Performance 3.68 hours · Measure score 2.12 · Achievement 2.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 15.87% · Lower 95% interval 7.54% |
| Discharge to community | 36.25% |
50.57%
14.3 pts worse
|
Worse than the National Rate · Eligible stays 79 · Observed rate 24.05% · Lower 95% interval 24.12% |
| Medicare spending per beneficiary | 1.53 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 98.18% |
95.27%
2.9 pts better
|
Numerator 54 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 21 · Denominator 33 |
| Discharge mobility score | 39.39% |
50.94%
11.5 pts worse
|
Numerator 13 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 10.91% |
2.29%
8.6 pts worse
|
Numerator 6 · Denominator 55 · Adjusted rate 8.56% |
| Healthcare-associated infections requiring hospitalization | 7.63% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 13.64% · Lower 95% interval 4.53% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 82 · Denominator 82 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 18 · Denominator 33 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.67% |
25.2%
18.5 pts worse
|
Numerator 2 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.2 · 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 | 86.2% |
97.9%
11.7 pts worse
|
95.5%
9.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.3%
2.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.0% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
3.3%
4.9 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 10.0% · Q4 4.5% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
18.9%
2.1 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 20.8% · Q3 9.1% · Q4 12.0% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.3% |
10.8%
7.5 pts worse
|
16.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.1% · Q4 20.0% · 4Q avg 18.3% · 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 need for help with daily activities has increased | 17.9% |
16.1%
1.8 pts worse
|
14.9%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 21.7% · Q4 25.0% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
0.5%
3.5 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q4 1.9% · 4Q avg 4.0% · 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 | 2.4% |
15.0%
12.6 pts better
|
19.8%
17.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q4 4.6% · 4Q avg 2.4% |
| Percentage of long-stay residents with pressure ulcers | 11.0% |
4.2%
6.8 pts worse
|
5.1%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.0% · Q3 14.0% · Q4 12.2% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
89.7%
9.4 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 98.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
12.0%
3.4 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 10.0% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.5% |
88.0%
13.5 pts worse
|
79.7%
5.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
25.9%
1.4 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 27.5% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2024-08-01
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-05-23 · Fire 2023-05-23
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-10-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-03
F · Potential for more than minimal harm
2025-10-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-10-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-03
E · Potential for more than minimal harm
2024-08-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-20
F · Potential for more than minimal harm
2023-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-14
E · Potential for more than minimal harm
2023-05-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-14
Inspection history
Recent health citations
K · Immediate jeopardy
2024-11-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-11-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-08-01
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 2024-08-20
D · Potential for more than minimal harm
2024-08-01
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 2024-08-20
F · Potential for more than minimal harm
2023-05-23
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 2023-06-09
E · Potential for more than minimal harm
2023-05-23
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 2023-06-09
D · Potential for more than minimal harm
2023-05-23
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-23
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-09
C · Minimal harm
2023-05-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-06-09
Penalties and ownership
What sits behind the stars
$56,103
2024-11-13
Fine
Fine · fine $56,103
Fine
Ownership
The American Cornerstone Health Services Inc.
5% Or Greater Direct Ownership Interest · Organization
Ajayi, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Ajayi, Temitope
5% Or Greater Indirect Ownership Interest · Individual
Ajayi, Samuel
Operational/Managerial Control · Individual
Ballew, Vincent
Operational/Managerial Control · Individual
Nwankwo, Chinedu
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Windsor Quail Valley Post-Acute Healthcare
Missouri City, TX
2-star overall rating with 3-star inspections with $52,036 in total fines with 3 recent health deficiencies
#2
Park Manor of Quail Valley
Missouri City, TX
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Paradigm At First Colony
Missouri City, TX
1-star overall rating with 1-star inspections with $211,113 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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