Cycle 1
Health 2025-06-19 · Fire 2025-06-19
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Houston, TX
Garden Terrace Healthcare Center Of Houston
3-star overall rating with 2-star inspections with $154,564 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
7887 Cambridge St, Houston, TX
(713) 796-2777
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1997-03-24
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
194 facilities
Chain averages 4 overall / 3 health / 3 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
0.94
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,272
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.50% · Performance 21.81% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.47
Baseline 6.06% · Performance 6.20% · Measure score 5.47 · Achievement 5.47 · Improvement 0
Total nurse turnover
1.73
Baseline 41.18% · Performance 56.60% · Measure score 1.73 · Achievement 1.73 · Improvement 0
Adjusted total nurse staffing
2.48
Baseline 3.87 hours · Performance 3.78 hours · Measure score 2.48 · Achievement 2.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.35% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 188 · Observed rate 13.3% · Lower 95% interval 9.05% |
| Discharge to community | 57.74% |
50.57%
7.2 pts better
|
No Different than the National Rate · Eligible stays 207 · Observed rate 43.96% · Lower 95% interval 49.22% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 72.73% |
95.27%
22.5 pts worse
|
Numerator 104 · Denominator 143 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 143 |
| Discharge self-care score | 76.47% |
53.69%
22.8 pts better
|
Numerator 65 · Denominator 85 |
| Discharge mobility score | 62.35% |
50.94%
11.4 pts better
|
Numerator 53 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 0.7% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 143 · Adjusted rate 0.5% |
| Healthcare-associated infections requiring hospitalization | 6.2% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 6.61% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | 17.5% |
42%
24.5 pts worse
|
Numerator 21 · Denominator 120 |
| Discharge function score | 82.35% |
56.45%
25.9 pts better
|
Numerator 70 · Denominator 85 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 57 · Denominator 57 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 15.58% |
25.2%
9.6 pts worse
|
Numerator 12 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.3%
2.7 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.9% |
2.7%
8.2 pts worse
|
11.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
18.9%
0.7 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
10.8%
3.1 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.0% |
16.1%
16.1 pts better
|
14.9%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
15.0%
12.7 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.2%
2.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · 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 99.2% · Q2 99.6% · Q3 99.6% · Q4 99.6% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
12.0%
0.4 pts worse
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 15.5% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.6% · Q3 0.6% · Q4 1.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.6% |
88.0%
5.6 pts better
|
79.7%
13.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
25.9%
1.4 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 38.8% · Expected 33.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-03-24 · Fire 2023-03-24
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-06-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-06-19
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-07-01
F · Potential for more than minimal harm
2024-05-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-21
F · Potential for more than minimal harm
2023-03-24
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-24
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-05-03
Inspection history
Recent health citations
K · Immediate jeopardy
2025-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Not marked corrected
E · Potential for more than minimal harm
2025-06-19
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-11
K · Immediate jeopardy
2024-07-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-05-23
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-23
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 2024-06-21
H · Actual harm
2023-11-01
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 2023-12-09
G · Actual harm
2023-11-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-09
E · Potential for more than minimal harm
2023-11-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-01
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 2023-12-09
D · Potential for more than minimal harm
2023-11-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-01
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 2023-12-09
D · Potential for more than minimal harm
2023-10-05
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-07-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-03-24
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 2023-05-06
D · Potential for more than minimal harm
2023-03-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-06
Penalties and ownership
What sits behind the stars
$48,840
2025-12-09
Fine
Fine · fine $48,840
Fine
$54,094
2024-07-10
Fine
Fine · fine $54,094
Fine
$51,630
2023-10-05
Fine
Fine · fine $51,630
Fine
Ownership
Preston, Forrest
5% Or Greater Direct Ownership Interest · Individual
Cross, Cindy
Corporate Officer · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Thurmond, Joan
Corporate Officer · Individual
Washington, Rulkiya
W-2 Managing Employee · Individual
Nearby options
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#2
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5-star overall rating with 5-star inspections
#3
Bayou Manor
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5-star overall rating with 5-star inspections with $57,184 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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