Cycle 1
Health 2025-09-17 · Fire 2025-09-17
15 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Houston, TX
Copperfield Healthcare and Rehabilitation
3-star overall rating with 2-star inspections with $35,430 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
7107 Queenston Blvd, Houston, TX
(281) 463-7333
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2009-08-12
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
0.60
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,051
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.46% · Performance 21.59% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.94% · Performance 7.70% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.74
Baseline 51.43% · Performance 52.48% · Measure score 2.74 · Achievement 2.74 · Improvement 0
Adjusted total nurse staffing
0.76
Baseline 3.22 hours · Performance 3.29 hours · Measure score 0.76 · Achievement 0.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 9.4% · Lower 95% interval 6.91% |
| Discharge to community | 57.49% |
50.57%
6.9 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 48.95% · Lower 95% interval 50.37% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.62% |
95.27%
2.4 pts better
|
Numerator 82 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 39.29% |
53.69%
14.4 pts worse
|
Numerator 22 · Denominator 56 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 24 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 3 · Denominator 84 · Adjusted rate 2.77% |
| Healthcare-associated infections requiring hospitalization | 7.7% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 9.72% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 221 |
| Staff flu vaccination coverage | 24.58% |
42%
17.4 pts worse
|
Numerator 59 · Denominator 240 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 26 · Denominator 56 |
| Transfer of health information to provider | 92.86% |
95.95%
3.1 pts worse
|
Numerator 26 · Denominator 28 |
| Transfer of health information to patient | 92.86% |
96.28%
3.4 pts worse
|
Numerator 26 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
97.1%
1.7 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 94.8% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
97.9%
1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.3%
0.3 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.6% · Q3 3.6% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
2.7%
2 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.3%
1.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.2% · Q4 5.5% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
18.9%
10.4 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 9.0% · Q3 9.9% · Q4 4.1% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
10.8%
8.5 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.6% · Q3 3.2% · Q4 0.0% · 4Q avg 2.3% · 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 | 7.7% |
15.4%
7.7 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 22.2% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.1%
6.8 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 5.5% · Q3 5.4% · Q4 26.9% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.6% |
15.0%
2.4 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 18.6% · Q3 2.4% · Q4 11.9% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.2%
1.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 3.1% · Q4 1.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
89.7%
4.4 pts better
|
81.7%
12.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 95.1% · Q3 97.7% · Q4 96.0% · 4Q avg 94.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
12.0%
7.4 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.7% · Expected 11.5% · 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 0.7% · Q2 0.6% · Q3 0.0% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
88.0%
6.4 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
25.9%
4.7 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 23.5% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-26 · Fire 2024-07-26
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-18 · Fire 2023-05-18
10 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
D · Potential for more than minimal harm
2025-09-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-10
Inspection history
Recent health citations
K · Immediate jeopardy
2025-09-17
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-10-11
J · Immediate jeopardy
2025-09-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-11
J · Immediate jeopardy
2025-09-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-11
E · Potential for more than minimal harm
2025-09-17
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 2025-10-11
E · Potential for more than minimal harm
2025-09-17
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-10-11
E · Potential for more than minimal harm
2025-09-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-11
E · Potential for more than minimal harm
2025-09-17
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-10-11
D · Potential for more than minimal harm
2025-09-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-11
D · Potential for more than minimal harm
2025-09-17
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-10-11
D · Potential for more than minimal harm
2025-09-17
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 2025-10-11
D · Potential for more than minimal harm
2025-09-17
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 2025-10-11
D · Potential for more than minimal harm
2025-09-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-11
D · Potential for more than minimal harm
2025-09-17
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 2025-10-11
D · Potential for more than minimal harm
2025-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-11
E · Potential for more than minimal harm
2025-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-24
E · Potential for more than minimal harm
2024-07-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-26
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 2024-08-23
D · Potential for more than minimal harm
2024-07-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-08-23
E · Potential for more than minimal harm
2023-05-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-10
E · Potential for more than minimal harm
2023-05-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-10
E · Potential for more than minimal harm
2023-05-18
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 2023-06-10
E · Potential for more than minimal harm
2023-05-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-10
D · Potential for more than minimal harm
2023-05-18
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-10
D · Potential for more than minimal harm
2023-05-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-10
D · Potential for more than minimal harm
2023-05-18
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 2023-06-10
D · Potential for more than minimal harm
2023-05-18
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 2023-06-10
D · Potential for more than minimal harm
2023-05-18
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 2023-06-10
D · Potential for more than minimal harm
2023-03-09
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 2023-03-20
Penalties and ownership
What sits behind the stars
$35,430
2025-09-17
Fine
Fine · fine $35,430
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cardon, Trevor
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Queenston Healthcare, Inc.
Operational/Managerial Control · Organization
Stratton, Charles
Corporate Officer · Individual
Zamora, Noe
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Cypress Pointe Health & Wellness
Houston, TX
5-star overall rating with 5-star inspections with $8,018 in total fines
#2
Eagle Crest Rapid Recovery
Houston, TX
2-star overall rating with 1-star inspections with $40,221 in total fines with 16 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Cypress Creek Rehabilitation and Healthcare Center
Cypress, TX
2-star overall rating with 2-star inspections with abuse icon flag with $74,263 in total fines with 8 recent health deficiencies
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