Cycle 1
Health 2024-11-07 · Fire 2024-11-07
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Friendswood, TX
Friendship Haven Healthcare and Rehabilitation Cen
4-star overall rating with 4-star inspections with $8,018 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1500 Sunset Dr, Friendswood, TX
(281) 992-4300
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hmg Healthcare
Operator or chain grouping
Approved since
1998-03-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 2 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
0.36
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,977
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.2
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.71
Baseline 23.08% · Performance 20.53% · Measure score 3.71 · Achievement 1.95 · Improvement 3.71
Healthcare-associated infections
3.98
Baseline 10.15% · Performance 7.84% · Measure score 3.98 · Achievement 0 · Improvement 3.98
Total nurse turnover
2.71
Baseline 58.43% · Performance 52.59% · Measure score 2.71 · Achievement 2.71 · Improvement 1.24
Adjusted total nurse staffing
0.87
Baseline 2.85 hours · Performance 3.25 hours · Measure score 0.87 · Achievement 0.61 · Improvement 0.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.58% |
10.72%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 159 · Observed rate 18.24% · Lower 95% interval 10.65% |
| Discharge to community | 41.17% |
50.57%
9.4 pts worse
|
Worse than the National Rate · Eligible stays 113 · Observed rate 30.97% · Lower 95% interval 32.32% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 81 · Denominator 81 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 81 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 28 · Denominator 49 |
| Discharge mobility score | 55.1% |
50.94%
4.2 pts better
|
Numerator 27 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 81 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.84% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 10% · Lower 95% interval 4.9% |
| Staff COVID-19 vaccination coverage | 0.71% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 141 |
| Staff flu vaccination coverage | 14.08% |
42%
27.9 pts worse
|
Numerator 20 · Denominator 142 |
| Discharge function score | 69.39% |
56.45%
12.9 pts better
|
Numerator 34 · Denominator 49 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 25 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 5.1 |
2.1
3 pts worse
|
1.9
3.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.1 · Observed 5.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.1 · Expected 1.6 · 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 | 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 | 1.1% |
3.3%
2.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
3.3%
4.1 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 13.3% · Q3 11.8% · Q4 4.7% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
18.9%
5.2 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 14.4% · Q3 13.6% · Q4 14.1% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
10.8%
1.6 pts worse
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.7% · Q3 15.7% · Q4 8.7% · 4Q avg 12.4% · 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 | 13.2% |
15.4%
2.2 pts better
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 9.7% · Q3 11.0% · Q4 30.8% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
16.1%
1.9 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 4.8% · Q3 3.8% · Q4 26.3% · 4Q avg 14.2% · 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 | 11.6% |
15.0%
3.4 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.4% · Q3 9.2% · Q4 18.8% · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.2%
1.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.4% · Q3 3.2% · Q4 3.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.3% |
12.0%
6.3 pts worse
|
12.0%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 19.6% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.6% · Q3 0.8% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
88.0%
10 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| 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 32.6% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-01 · Fire 2023-09-01
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-06-16 · Fire 2022-06-16
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-06
F · Potential for more than minimal harm
2023-09-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-22
F · Potential for more than minimal harm
2023-09-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-04
E · Potential for more than minimal harm
2023-09-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
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 2026-01-12
D · Potential for more than minimal harm
2025-09-04
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 2026-01-12
E · Potential for more than minimal harm
2025-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
G · Actual harm
2024-11-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-11-07
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-04
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 2024-09-27
G · Actual harm
2023-09-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-09-01
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 2023-09-04
E · Potential for more than minimal harm
2023-09-01
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 2023-09-16
D · Potential for more than minimal harm
2023-09-01
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 2023-09-30
D · Potential for more than minimal harm
2023-09-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-16
D · Potential for more than minimal harm
2023-09-01
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-09-04
D · Potential for more than minimal harm
2023-09-01
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 2023-09-30
D · Potential for more than minimal harm
2023-04-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-26
E · Potential for more than minimal harm
2022-06-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-24
E · Potential for more than minimal harm
2022-06-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-06-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-06-16
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 2022-06-24
Penalties and ownership
What sits behind the stars
$8,018
2024-11-07
Fine
Fine · fine $8,018
Fine
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Balsamo, Krystal
Operational/Managerial Control · Individual
Cibc Bank Usa
Operational/Managerial Control · Organization
Culp, Roland
5% Or Greater Indirect Ownership Interest · Individual
Culp, Roland
Operational/Managerial Control · Individual
Daspit, Laurence
5% Or Greater Indirect Ownership Interest · Individual
Daspit, Laurence
Operational/Managerial Control · Individual
Dohn, William
Operational/Managerial Control · Individual
Friendswood Trs LLC
Operational/Managerial Control · Organization
Murrell, Edward
Operational/Managerial Control · Individual
Murrell, Edward
Corporate Officer · Individual
Naeseth, Joddie
Operational/Managerial Control · Individual
Nodarse, Yeisleny
Operational/Managerial Control · Individual
Pico, Ana
5% Or Greater Indirect Ownership Interest · Individual
Pico, Ana
Operational/Managerial Control · Individual
Prince, Derek
5% Or Greater Indirect Ownership Interest · Individual
Prince, Derek
Operational/Managerial Control · Individual
Reinarz, Christian
Operational/Managerial Control · Individual
Rollo, Jeffery
Operational/Managerial Control · Individual
Rollo, Jeffery
Corporate Officer · Individual
Stramecki, Anthony
Operational/Managerial Control · Individual
Stramecki, Anthony
Corporate Director · Individual
Vratis, Kacey
Operational/Managerial Control · Individual
Walsh, Brent
Operational/Managerial Control · Individual
Way, George
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Regency Village
Webster, TX
1-star overall rating with 2-star inspections with abuse icon flag with $22,718 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Ignite Medical Resort Webster, LLC
Webster, TX
5-star overall rating with 5-star inspections with $42,280 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Focused Care at Webster
Webster, TX
1-star overall rating with 1-star inspections with abuse icon flag with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out