Cycle 1
Health 2024-06-01 · Fire 2024-06-01
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Houston, TX
Houston Transitional Care
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
8550 Jason Street, Houston, TX
(346) 231-7502
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
70
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2017-12-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.60
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
2.10
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.61
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
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,844
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.82
Baseline 21.61% · Performance 18.27% · Measure score 6.82 · Achievement 6.82 · Improvement 6.79
Healthcare-associated infections
0
Baseline 4.94% · Performance 8.23% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.11
Baseline 67.53% · Performance 56.41% · Measure score 2.11 · Achievement 1.78 · Improvement 2.11
Adjusted total nurse staffing
0
Baseline 3.33 hours · Performance 2.68 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.28% |
10.72%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 171 · Observed rate 21.05% · Lower 95% interval 9.74% |
| Discharge to community | 54.12% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 38.8% · Lower 95% interval 47.05% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 114 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 59.38% |
53.69%
5.7 pts better
|
Numerator 38 · Denominator 64 |
| Discharge mobility score | 39.06% |
50.94%
11.9 pts worse
|
Numerator 25 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 115 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.23% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 14.44% · Lower 95% interval 6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 21.05% |
42%
20.9 pts worse
|
Numerator 8 · Denominator 38 |
| Discharge function score | 48.44% |
56.45%
8 pts worse
|
Numerator 31 · Denominator 64 |
| Transfer of health information to provider | 94.83% |
95.95%
1.1 pts worse
|
Numerator 55 · Denominator 58 |
| Transfer of health information to patient | 96.43% |
96.28%
0.2 pts better
|
Numerator 54 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 17.39% |
25.2%
7.8 pts worse
|
Numerator 12 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 3.5 · Expected 3.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.9 · Expected 2.0 · 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 | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 42.4% |
2.7%
39.7 pts worse
|
11.4%
31 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 39.4% · Q3 40.6% · Q4 48.4% · 4Q avg 42.4% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
18.9%
18.9 pts better
|
19.6%
19.6 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 received an antipsychotic medication | 8.6% |
10.8%
2.2 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · 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 | 3.2% |
15.4%
12.2 pts better
|
16.3%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
16.1%
7.6 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 13.3% · Q3 6.7% · Q4 7.1% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.5%
0.7 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.6% · 4Q avg 1.2% · 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 | 11.4% |
15.0%
3.6 pts better
|
19.8%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 11.8% · Q3 12.5% · Q4 6.3% · 4Q avg 11.4% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
4.2%
3.1 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.3% · Q3 3.3% · Q4 7.4% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
89.7%
10.2 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
12.0%
5.1 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 8.7% · Expected 14.0% · 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 · Q1 0.0% · Q2 0.0% · 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 | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
25.9%
2.2 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 32.7% · Expected 32.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-11 · Fire 2023-05-11
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-03-10 · Fire 2022-03-10
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-04
E · Potential for more than minimal harm
2024-06-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-04
D · Potential for more than minimal harm
2023-05-11
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 2023-05-29
C · Minimal harm
2023-05-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-29
F · Potential for more than minimal harm
2022-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-06-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-06-01
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 2024-06-05
D · Potential for more than minimal harm
2024-06-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-06-01
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 2024-06-05
C · Minimal harm
2024-06-01
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-06-05
E · Potential for more than minimal harm
2023-05-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-05-11
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 2023-05-29
D · Potential for more than minimal harm
2023-05-11
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 2023-05-29
D · Potential for more than minimal harm
2023-05-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-29
F · Potential for more than minimal harm
2022-03-10
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 2022-04-08
E · Potential for more than minimal harm
2022-03-10
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 2022-03-29
E · Potential for more than minimal harm
2022-03-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-03-10
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 2022-03-29
D · Potential for more than minimal harm
2022-03-10
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 2022-03-29
D · Potential for more than minimal harm
2022-03-10
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 2022-04-08
Penalties and ownership
What sits behind the stars
Ownership
Mainstreeidence Developments LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
El-Saadi, Ahmad
Operational/Managerial Control · Individual
El-Saadi, Ahmad
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Phan, Hoang-Anh
Contracted Managing Employee · Individual
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Seven Acres Jewish Senior Care Services
Houston, TX
3-star overall rating with 3-star inspections with $25,454 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Clarewood House Extended Care Center
Houston, TX
3-star overall rating with 3-star inspections with $38,877 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Sharpville Residence and Rehabilitation Center
Houston, TX
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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