Cycle 1
Health 2025-01-10 · Fire 2025-01-10
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Katy, TX
Falcon Point Post Acute
3-star overall rating with 4-star inspections with $19,684 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
23553 West Fernhurst Drive, Katy, TX
(281) 394-3900
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cross Healthcare Management
Operator or chain grouping
Approved since
2008-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 1 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
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
73%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,411
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.55% · Performance 22.79% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.66% · Performance 7.69% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 62.07% · Performance 69.79% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.21
Baseline 3.89 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.29% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 14.58% · Lower 95% interval 8.58% |
| Discharge to community | 57.02% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 51.55% · Lower 95% interval 48.67% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 75.81% |
95.27%
19.5 pts worse
|
Numerator 94 · Denominator 124 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 124 |
| Discharge self-care score | 37.36% |
53.69%
16.3 pts worse
|
Numerator 34 · Denominator 91 |
| Discharge mobility score | 34.07% |
50.94%
16.9 pts worse
|
Numerator 31 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 4.84% |
2.29%
2.5 pts worse
|
Numerator 6 · Denominator 124 · Adjusted rate 3.72% |
| Healthcare-associated infections requiring hospitalization | 7.69% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 10.75% · Lower 95% interval 4.7% |
| Staff COVID-19 vaccination coverage | 42.86% |
8.2%
34.7 pts better
|
Numerator 69 · Denominator 161 |
| Staff flu vaccination coverage | 7.59% |
42%
34.4 pts worse
|
Numerator 12 · Denominator 158 |
| Discharge function score | 34.07% |
56.45%
22.4 pts worse
|
Numerator 31 · Denominator 91 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | 90.7% |
96.28%
5.6 pts worse
|
Numerator 39 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 3.51% |
25.2%
21.7 pts worse
|
Numerator 2 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · 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 | 96.7% |
97.9%
1.2 pts worse
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.3%
0.9 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.5% · Q3 7.2% · Q4 4.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
3.3%
4.3 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 10.8% · Q3 3.0% · Q4 4.3% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
18.9%
4.2 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 13.2% · Q3 13.4% · Q4 14.1% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
10.8%
0.2 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 10.2% · Q3 9.4% · Q4 10.4% · 4Q avg 10.6% · 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 | 6.3% |
15.4%
9.1 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.2% · Q3 4.6% · Q4 10.3% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
16.1%
9.9 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 3.2% · Q3 3.3% · Q4 8.1% · 4Q avg 6.2% · 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 | 0.0% |
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 | 20.5% |
15.0%
5.5 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 23.3% · Q3 25.1% · Q4 16.5% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.2%
2.1 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.4% · Q3 5.7% · Q4 3.6% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
89.7%
9.8 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.4% · Q4 98.7% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
12.0%
2.5 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 14.0% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
88.0%
8.7 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.2% |
25.9%
8.3 pts worse
|
23.9%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.2% · Observed 33.3% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-17 · Fire 2023-11-17
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-09-15 · Fire 2022-09-15
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-29
F · Potential for more than minimal harm
2025-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-30
F · Potential for more than minimal harm
2025-01-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-28
D · Potential for more than minimal harm
2025-01-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-28
J · Immediate jeopardy
2024-05-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-11
F · Potential for more than minimal harm
2023-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-31
E · Potential for more than minimal harm
2023-11-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-15
D · Potential for more than minimal harm
2026-01-08
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 2026-01-15
D · Potential for more than minimal harm
2025-12-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-01-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-28
E · Potential for more than minimal harm
2025-01-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-10
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 2025-01-28
E · Potential for more than minimal harm
2025-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-28
D · Potential for more than minimal harm
2025-01-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-28
D · Potential for more than minimal harm
2025-01-10
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 2025-01-29
D · Potential for more than minimal harm
2025-01-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-11-04
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-04
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 2024-11-26
C · Minimal harm
2024-05-19
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-05-20
F · Potential for more than minimal harm
2023-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-17
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 2023-12-12
D · Potential for more than minimal harm
2023-11-17
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-12-12
E · Potential for more than minimal harm
2022-09-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-09-15
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 2022-10-03
E · Potential for more than minimal harm
2022-09-15
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 2022-10-03
D · Potential for more than minimal harm
2022-09-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-09-15
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 2022-10-12
D · Potential for more than minimal harm
2022-09-15
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 2022-10-12
D · Potential for more than minimal harm
2022-09-15
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 2022-10-03
D · Potential for more than minimal harm
2022-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-03
Penalties and ownership
What sits behind the stars
$19,684
2024-05-19
Fine
Fine · fine $19,684
Fine
Ownership
West Coke County Hospital District
5% Or Greater Direct Ownership Interest · Organization
23553wfd, LLC
5% Or Greater Mortgage Interest · Organization
Ali, Nida
Operational/Managerial Control · Individual
Falcon Point Opco LLC
Operational/Managerial Control · Organization
Ktfw-Tx LLC
5% Or Greater Mortgage Interest · Organization
Martin, Christopher
Operational/Managerial Control · Individual
Mcguire, Wesley
Corporate Officer · Individual
Rankin, Derek
Operational/Managerial Control · Individual
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#3
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