Cycle 1
Health 2025-04-30 · Fire 2025-04-30
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cleveland, TX
Cleveland Health Care Center
4-star overall rating with 4-star inspections with $30,198 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
903 E Houston St, Cleveland, TX
(281) 593-3737
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
142
Certified beds
Average residents
83
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Health Services Management
Operator or chain grouping
Approved since
1991-09-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 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
0.14
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.16
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,220
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9903
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.82% · Performance 22.58% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.42
Baseline 8.52% · Performance 5.73% · Measure score 7.42 · Achievement 7.05 · Improvement 7.42
Total nurse turnover
3.88
Performance 47.83% · Measure score 3.88 · Achievement 3.88 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.49
Baseline 4.70 hours · Performance 4.07 hours · Measure score 3.49 · Achievement 3.49 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 12.5% · Lower 95% interval 6.99% |
| Discharge to community | 58.21% |
50.57%
7.6 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 43.66% · Lower 95% interval 45.52% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.18% |
95.27%
2.1 pts worse
|
Numerator 41 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 35.71% |
53.69%
18 pts worse
|
Numerator 10 · Denominator 28 |
| Discharge mobility score | 35.71% |
50.94%
15.2 pts worse
|
Numerator 10 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 6.82% |
2.29%
4.5 pts worse
|
Numerator 3 · Denominator 44 · Adjusted rate 6.35% |
| Healthcare-associated infections requiring hospitalization | 5.73% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 2.08% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | 14.02% |
42%
28 pts worse
|
Numerator 15 · Denominator 107 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 12 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.9 · 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 2.0 · Expected 1.9 · 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 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.5% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
97.9%
3.3 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.3%
3.3 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 7.4% · Q3 5.9% · Q4 6.0% · 4Q avg 6.6% · 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 | 2.7% |
3.3%
0.6 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 1.9% · Q3 1.7% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.3% |
18.9%
5.4 pts worse
|
19.6%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 24.1% · Q3 25.0% · Q4 23.7% · 4Q avg 24.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.3% |
10.8%
9.5 pts worse
|
16.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 21.4% · Q3 22.4% · Q4 17.8% · 4Q avg 20.3% · 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 ability to walk independently worsened | 15.9% |
15.4%
0.5 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 52.7% · Q2 8.9% · Q3 3.6% · Q4 3.6% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
16.1%
3.4 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.8% · Q2 21.7% · Q3 7.7% · Q4 5.8% · 4Q avg 19.5% · 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 | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.8% |
15.0%
0.8 pts worse
|
19.8%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 13.1% · Q3 13.8% · Q4 16.8% · 4Q avg 15.8% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.2%
0.1 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.2% · Q3 1.4% · Q4 3.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.2% |
89.7%
9.5 pts worse
|
81.7%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 86.1% · Q3 86.5% · Q4 65.2% · 4Q avg 80.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
12.0%
1.1 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 14.3% · Expected 14.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 4.7% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
88.0%
0.7 pts worse
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
25.9%
2.1 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 35.7% · Expected 30.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-13 · Fire 2024-03-13
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-02-07 · Fire 2023-02-07
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-15
C · Minimal harm
2025-04-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2024-03-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-04
C · Minimal harm
2024-03-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2023-02-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-08
C · Minimal harm
2023-02-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-01-01
D · Potential for more than minimal harm
2025-04-30
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 2025-05-15
G · Actual harm
2024-08-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-29
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-03-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-03-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-13
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 2024-03-28
J · Immediate jeopardy
2023-08-28
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 2023-08-29
J · Immediate jeopardy
2023-08-28
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 2023-08-29
D · Potential for more than minimal harm
2023-08-28
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 2023-08-29
D · Potential for more than minimal harm
2023-02-07
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 2023-02-08
D · Potential for more than minimal harm
2023-02-07
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-02-17
Penalties and ownership
What sits behind the stars
$16,801
2024-08-29
Fine
Fine · fine $16,801
Fine
$13,397
2023-08-28
Fine
Fine · fine $13,397
Fine
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Cleveland Realty, LLC
5% Or Greater Mortgage Interest · Organization
Hampton, Tamra
Operational/Managerial Control · Individual
Health Services Management, Inc.
5% Or Greater Mortgage Interest · Organization
Hsmtx/Cleveland, LLC
Operational/Managerial Control · Organization
Murrell, Edward
Corporate Director · Individual
White, Joshua
Operational/Managerial Control · Individual
Nearby options
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#3
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