Cycle 1
Health 2024-12-20 · Fire 2024-12-20
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Houston, TX
Cypress Pointe Health & Wellness
5-star overall rating with 5-star inspections with $8,018 in total fines
8561 Easton Commons Dr., Houston, TX
(832) 497-5479
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ml Healthcare
Operator or chain grouping
Approved since
2020-04-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 1 staffing / 5 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
0.53
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
68%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,577
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.58
Baseline 20.15% · Performance 19.77% · Measure score 3.58 · Achievement 3.58 · Improvement 0.71
Healthcare-associated infections
1.53
Baseline 8.41% · Performance 7.72% · Measure score 1.53 · Achievement 0 · Improvement 1.53
Total nurse turnover
2.84
Baseline 59.34% · Performance 52.08% · Measure score 2.84 · Achievement 2.84 · Improvement 1.60
Adjusted total nurse staffing
0
Baseline 3.01 hours · Performance 2.85 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 11.72% · Lower 95% interval 7.95% |
| Discharge to community | 65.1% |
50.57%
14.5 pts better
|
Better than the National Rate · Eligible stays 151 · Observed rate 52.98% · Lower 95% interval 56.05% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 99.35% |
95.27%
4.1 pts better
|
Numerator 154 · Denominator 155 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 155 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 52 · Denominator 91 |
| Discharge mobility score | 40.66% |
50.94%
10.3 pts worse
|
Numerator 37 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 0.65% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 155 · Adjusted rate 0.58% |
| Healthcare-associated infections requiring hospitalization | 7.72% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 10% · Lower 95% interval 5.08% |
| Staff COVID-19 vaccination coverage | 1.92% |
8.2%
6.3 pts worse
|
Numerator 3 · Denominator 156 |
| Staff flu vaccination coverage | 61.17% |
42%
19.2 pts better
|
Numerator 126 · Denominator 206 |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 42 · Denominator 91 |
| Transfer of health information to provider | 98.21% |
95.95%
2.3 pts better
|
Numerator 55 · Denominator 56 |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 66 · Denominator 69 |
| Resident COVID-19 vaccinations up to date | 27.27% |
25.2%
2.1 pts better
|
Numerator 27 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
97.1%
1.1 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 97.6% · Q3 98.9% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.9%
0.9 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 2.3% · Q4 1.2% · 4Q avg 1.5% · 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 | 1.7% |
3.3%
1.6 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 2.6% · Q4 1.5% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
18.9%
0.5 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 17.8% · Q3 19.5% · Q4 23.5% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
10.8%
0.3 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 12.3% · Q3 10.9% · Q4 10.3% · 4Q avg 10.5% · 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 | 8.0% |
15.4%
7.4 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
16.1%
9 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.7% · Q3 11.3% · Q4 10.7% · 4Q avg 7.1% · 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 | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.1% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.9% |
15.0%
3.1 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 8.8% · Q3 13.4% · Q4 18.1% · 4Q avg 11.9% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.2%
0.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.2% · Q3 3.7% · Q4 3.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
89.7%
5.8 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 96.9% · Q3 99.5% · Q4 93.4% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
12.0%
1.6 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 11.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
88.0%
5.3 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
25.9%
2.7 pts better
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 28.0% · Expected 28.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-08-18
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-09-01
Inspection history
Recent health citations
G · Actual harm
2024-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-12
D · Potential for more than minimal harm
2023-11-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-11-16
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 2023-12-17
E · Potential for more than minimal harm
2022-08-18
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 2022-09-07
D · Potential for more than minimal harm
2022-08-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-07
Penalties and ownership
What sits behind the stars
$8,018
2024-06-14
Fine
Fine · fine $8,018
Fine
Ownership
Frio Hospital District
5% Or Greater Direct Ownership Interest · Organization
Ali, Nida
Operational/Managerial Control · Individual
Langsdale, Troy
Operational/Managerial Control · Individual
Langsdale, Troy
5% Or Greater Mortgage Interest · Individual
Miller, Laura
Operational/Managerial Control · Individual
Miller, Laura
5% Or Greater Mortgage Interest · Individual
Ml - Easton Commons LLC
Operational/Managerial Control · Organization
Ml Real Estate-Easton Commons, LLC
5% Or Greater Mortgage Interest · Organization
Ruff, Michael
Corporate Officer · Individual
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#3
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