Cycle 1
Health 2025-06-27 · Fire 2025-06-27
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
Houston Heights Nursing and Rehabilitation Center
2-star overall rating with 2-star inspections with abuse icon flag with $109,995 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
6920 W T.C. Jester Blvd, Houston, TX
(713) 681-0431
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
120
Certified beds
Average residents
101
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2013-05-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 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
0.33
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.02
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.19
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
0.28
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,218
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 8.53% · Performance 9.16% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.29
Baseline 57.38% · Performance 42.05% · Measure score 5.29 · Achievement 5.29 · Improvement 4.21
Adjusted total nurse staffing
0
Baseline 3.07 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 48 · Observed rate 12.5% · Lower 95% interval 6.84% |
| Discharge to community | 45.73% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 32.14% · Lower 95% interval 30.73% |
| Medicare spending per beneficiary | 1.47 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 24 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.16% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 24.14% · Lower 95% interval 4.94% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 151 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 134 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
97.1%
1.6 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
97.9%
0.1 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
2.7%
2.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
3.3%
0.1 pts worse
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
18.9%
7.9 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 8.0% · Q3 10.3% · Q4 8.6% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
10.8%
1.7 pts worse
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 14.3% · Q3 13.4% · Q4 9.7% · 4Q avg 12.5% · 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 | 20.1% |
15.4%
4.7 pts worse
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 11.8% · Q4 13.4% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.8% |
16.1%
7.7 pts worse
|
14.9%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 32.5% · Q3 26.0% · Q4 15.1% · 4Q avg 23.8% · 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 | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.1% |
15.0%
2.9 pts better
|
19.8%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 18.6% · Q3 10.8% · Q4 3.1% · 4Q avg 12.1% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.5% · Q3 2.6% · Q4 1.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.8% |
89.7%
4.9 pts worse
|
81.7%
3.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 65.6% · Q2 83.8% · Q3 91.9% · Q4 94.9% · 4Q avg 84.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
12.0%
5.7 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 7.4% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.7% |
88.0%
12.3 pts worse
|
79.7%
4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.7% |
25.9%
2.8 pts worse
|
23.9%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 37.0% · Expected 30.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-27
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-30
F · Potential for more than minimal harm
2024-05-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-13
E · Potential for more than minimal harm
2023-04-06
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-04-20
Inspection history
Recent health citations
J · Immediate jeopardy
2025-06-27
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 2025-06-21
E · Potential for more than minimal harm
2025-06-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-06-27
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 2025-06-28
D · Potential for more than minimal harm
2025-06-17
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-06-18
H · Actual harm
2025-05-22
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 2025-06-12
G · Actual harm
2025-05-22
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 2025-06-22
D · Potential for more than minimal harm
2024-06-14
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 2024-07-05
D · Potential for more than minimal harm
2024-06-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-23
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 2024-06-13
J · Immediate jeopardy
2024-03-21
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 2024-03-23
E · Potential for more than minimal harm
2024-03-21
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-03-23
J · Immediate jeopardy
2024-01-22
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 2024-01-23
J · Immediate jeopardy
2024-01-22
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-23
E · Potential for more than minimal harm
2024-01-22
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 2024-04-30
E · Potential for more than minimal harm
2023-04-06
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 2023-04-20
D · Potential for more than minimal harm
2023-04-06
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 2023-04-20
D · Potential for more than minimal harm
2023-04-06
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 2023-04-20
C · Minimal harm
2023-04-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-03-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-09
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 2023-03-31
Penalties and ownership
What sits behind the stars
$12,740
2025-06-27
Fine
Fine · fine $12,740
Fine
$69,455
2025-05-22
Fine
Fine · fine $69,455
Fine
$13,900
2024-01-22
Fine
Fine · fine $13,900
Fine
$13,900
2024-01-22
Fine
Fine · fine $13,900
Fine
$0
2024-01-22
Payment Denial
Payment Denial · denial start 2024-02-20 · 70 days
70 day denial
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Carter, Elizabeth
Operational/Managerial Control · Individual
Dekowski, Donovan
Operational/Managerial Control · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Oakbend Medical Center
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Wellsential Of Houston Heights LLC
Operational/Managerial Control · Organization
Zaharia, Adrian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Caraday of Houston
Houston, TX
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
West Janisch Health Care Center
Houston, TX
1-star overall rating with 1-star inspections with abuse icon flag with $7,443 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Ashford Gardens
Houston, TX
4-star overall rating with 3-star inspections with $11,009 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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