Cycle 1
Health 2024-08-15 · Fire 2024-08-15
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
Continuing Care At Eagles Trace
4-star overall rating with 4-star inspections with $22,486 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
14703 Eagle Vista Drive Bldg 601b, Houston, TX
(281) 249-7189
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Erickson Senior Living
Operator or chain grouping
Approved since
2013-05-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 3 health / 5 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
1.06
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.60
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.00
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.25
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.79
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
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,815
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9955
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.97% · Performance 21.45% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.26
Baseline 6.23% · Performance 6.56% · Measure score 4.26 · Achievement 4.26 · Improvement 0
Total nurse turnover
4.53
Baseline 53.85% · Performance 45.16% · Measure score 4.53 · Achievement 4.53 · Improvement 2.50
Adjusted total nurse staffing
8.24
Baseline 4.72 hours · Performance 5.42 hours · Measure score 8.24 · Achievement 8.24 · Improvement 6.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 6.82% · Lower 95% interval 6.97% |
| Discharge to community | 57.91% |
50.57%
7.3 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 58.57% · Lower 95% interval 46.36% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.5% |
95.27%
2.2 pts better
|
Numerator 39 · Denominator 40 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 40 |
| Discharge self-care score | 32.26% |
53.69%
21.4 pts worse
|
Numerator 10 · Denominator 31 |
| Discharge mobility score | 22.58% |
50.94%
28.4 pts worse
|
Numerator 7 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 2 · Denominator 40 · Adjusted rate 4.35% |
| Healthcare-associated infections requiring hospitalization | 6.56% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 2.96% |
| Staff COVID-19 vaccination coverage | 5.26% |
8.2%
2.9 pts worse
|
Numerator 4 · Denominator 76 |
| Staff flu vaccination coverage | 36.55% |
42%
5.5 pts worse
|
Numerator 53 · Denominator 145 |
| Discharge function score | 25.81% |
56.45%
30.6 pts worse
|
Numerator 8 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 38.1% |
25.2%
12.9 pts better
|
Numerator 8 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
97.1%
2.1 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.2% · Q4 100.0% · 4Q avg 99.2% |
| 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 | 3.1% |
3.3%
0.2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.1% · Q3 0.0% · Q4 6.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
2.7%
4.5 pts worse
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.7% · Q3 5.9% · Q4 3.0% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
3.3%
1.9 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.8% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.4% |
18.9%
13.5 pts better
|
19.6%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.8% · Q4 9.5% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
10.8%
10.1 pts worse
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 20.0% · 4Q avg 20.9% · 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 | 22.2% |
16.1%
6.1 pts worse
|
14.9%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 19.0% · Q4 14.3% · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.0% |
0.8%
6.2 pts worse
|
1.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.5% · Q3 5.6% · Q4 12.1% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
15.0%
3.2 pts worse
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 15.8% · Q3 32.8% · Q4 11.5% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.2%
About the same
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.8% · Q3 3.3% · Q4 5.5% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
89.7%
6.9 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.5% · Q3 93.6% · Q4 92.3% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
12.0%
12 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
88.0%
10.5 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
25.9%
2 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 23.3% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-16 · Fire 2023-06-16
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-05-12 · Fire 2022-05-12
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-18
F · Potential for more than minimal harm
2023-06-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-16
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-07-18
E · Potential for more than minimal harm
2022-05-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-10
E · Potential for more than minimal harm
2022-05-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-15
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 2024-09-18
E · Potential for more than minimal harm
2024-08-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-15
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 2024-09-18
D · Potential for more than minimal harm
2024-08-15
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 2024-09-18
D · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-18
K · Immediate jeopardy
2023-11-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-07
K · Immediate jeopardy
2023-11-17
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 2023-11-04
D · Potential for more than minimal harm
2023-06-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-07-18
E · Potential for more than minimal harm
2022-05-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-06-14
Penalties and ownership
What sits behind the stars
$9,528
2023-11-17
Fine
Fine · fine $9,528
Fine
$12,958
2023-11-17
Fine
Fine · fine $12,958
Fine
Ownership
National Senior Communities, Inc
5% Or Greater Direct Ownership Interest · Organization
Oak Investment Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Oak Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Brown, Ian
Corporate Director · Individual
Brown, Patricia
Corporate Director · Individual
Buck, Karen
Operational/Managerial Control · Individual
Butler, Richard
Operational/Managerial Control · Individual
Clupper, Katherine
Corporate Director · Individual
Colins, Mary
Corporate Director · Individual
Colins, Mary
Corporate Officer · Individual
Embley, Mark
Operational/Managerial Control · Individual
Embley, Mark
Corporate Officer · Individual
Erickson Senior Living LLC
Operational/Managerial Control · Organization
Erstad, Eileen
Corporate Director · Individual
Erstad, Eileen
Corporate Officer · Individual
Gantert, Neal
Operational/Managerial Control · Individual
Gantert, Neal
Corporate Officer · Individual
Hall, John
Operational/Managerial Control · Individual
Hall, John
Corporate Officer · Individual
Jacque, Zina
Corporate Director · Individual
Leonard, Monty
Corporate Director · Individual
Moscato, Mary
Corporate Director · Individual
National Senior Communities, Inc
Operational/Managerial Control · Organization
Paulk, Pamela
Corporate Director · Individual
Paulk, Pamela
Corporate Officer · Individual
Pomeranz, William
Corporate Director · Individual
Reel, Stephanie
Corporate Director · Individual
Roskiewicz, Michael
Corporate Director · Individual
Roskiewicz, Michael
Corporate Officer · Individual
Sawicki, Scott
Corporate Officer · Individual
Sharp, Russel
Corporate Director · Individual
Stiner, Pamela
Operational/Managerial Control · Individual
Stiner, Pamela
Corporate Officer · Individual
Sweetser, Christian
Operational/Managerial Control · Individual
Tremaine, Brian
Operational/Managerial Control · Individual
Tyler, Daniel
Corporate Officer · Individual
Wallick, Daniel
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Avir at Houston
Houston, TX
2-star overall rating with 1-star inspections with $216,791 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Parkway Place
Houston, TX
4-star overall rating with 3-star inspections with $45,741 in total fines with 2 recent health deficiencies
#3
St Dominic Village Rehabilitation And Nursing Cent
Houston, TX
5-star overall rating with 5-star inspections with $29,561 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out