Cycle 1
Health 2025-06-29 · Fire 2025-06-29
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Kingwood, TX
Kingwood Rehabilitation and Healthcare Center
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $111,650 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
23775 Kingwood Place, Kingwood, TX
(281) 318-2600
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
194
Certified beds
Average residents
83
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Momentum Skilled Services
Operator or chain grouping
Approved since
2007-10-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 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
0.29
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.65
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
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
0.27
CMS adjusted RN staffing hours
Adjusted total hours
2.92
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,495
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
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
0.90
Baseline 6.50% · Performance 7.56% · Measure score 0.90 · Achievement 0.90 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.82 hours · Performance 2.95 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.54% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 14.29% · Lower 95% interval 8.09% |
| Discharge to community | 44.09% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 34.78% · Lower 95% interval 34.42% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 92.16% |
95.27%
3.1 pts worse
|
Numerator 47 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 2 · Denominator 50 · Adjusted rate 3.82% |
| Healthcare-associated infections requiring hospitalization | 7.57% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 129 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 129 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.1 · Expected 2.8 · 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 1.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.1%
2.3 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
97.9%
1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.3%
2.3 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.9% · Q3 8.4% · Q4 1.4% · 4Q avg 5.6% · 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 | 3.3% |
3.3%
About the same
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.3% · Q3 2.9% · Q4 3.1% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
18.9%
2.2 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 20.0% · Q3 13.5% · Q4 12.3% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
10.8%
2.6 pts worse
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 17.2% · Q3 8.9% · Q4 12.0% · 4Q avg 13.4% · 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 | 21.7% |
15.4%
6.3 pts worse
|
16.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 41.5% · Q3 19.3% · Q4 4.1% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
16.1%
1.9 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 35.9% · Q3 23.2% · Q4 4.8% · 4Q avg 18.0% · 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 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
15.0%
2.3 pts worse
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 24.1% · Q3 21.8% · Q4 10.5% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
4.2%
5.6 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 12.2% · Q3 7.3% · Q4 5.6% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.3% |
89.7%
18.4 pts worse
|
81.7%
10.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.5% · Q2 82.1% · Q3 68.9% · Q4 58.8% · 4Q avg 71.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
12.0%
6.3 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 6.7% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.5%
2.5 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.6% · Q3 2.4% · Q4 2.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
88.0%
8 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.9% |
25.9%
10 pts worse
|
23.9%
12 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.9% · Observed 46.7% · Expected 31.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-16 · Fire 2023-03-16
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-02
F · Potential for more than minimal harm
2024-05-16
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-06-06
E · Potential for more than minimal harm
2024-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-06
E · Potential for more than minimal harm
2023-03-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-14
Inspection history
Recent health citations
J · Immediate jeopardy
2025-06-29
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 2025-07-01
J · Immediate jeopardy
2025-06-29
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 2025-07-01
E · Potential for more than minimal harm
2025-06-29
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-06-29
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 2025-07-01
D · Potential for more than minimal harm
2025-06-29
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 2025-07-01
D · Potential for more than minimal harm
2025-06-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-01
K · Immediate jeopardy
2025-06-03
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 2025-06-28
K · Immediate jeopardy
2025-06-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-28
K · Immediate jeopardy
2025-06-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-28
K · Immediate jeopardy
2025-06-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-28
K · Immediate jeopardy
2025-06-03
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 2025-06-28
E · Potential for more than minimal harm
2024-05-16
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 2024-07-01
D · Potential for more than minimal harm
2024-05-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-16
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-16
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 2024-07-01
E · Potential for more than minimal harm
2023-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-04-26
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 2023-06-09
E · Potential for more than minimal harm
2023-03-16
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 2023-04-24
E · Potential for more than minimal harm
2023-03-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-16
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 2023-04-24
E · Potential for more than minimal harm
2023-03-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-16
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-16
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 2023-04-24
D · Potential for more than minimal harm
2023-03-16
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 2023-04-24
D · Potential for more than minimal harm
2023-03-16
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 2023-04-24
Penalties and ownership
What sits behind the stars
$111,650
2025-06-03
Fine
Fine · fine $111,650
Fine
Ownership
Uvalde County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Apolinar, Adam
Corporate Director · Individual
Fellbaum, Ernest
5% Or Greater Mortgage Interest · Individual
Fuze Ventures, LP
5% Or Greater Mortgage Interest · Organization
Healthcare Investments Rc, LLC
5% Or Greater Mortgage Interest · Organization
Krhc Re, LLC
5% Or Greater Mortgage Interest · Organization
Krhc, LLC
Operational/Managerial Control · Organization
M Ventures 111, LLC
5% Or Greater Mortgage Interest · Organization
Martel, Michael
5% Or Greater Mortgage Interest · Individual
Mmt Realty-Kingwood, LLC
5% Or Greater Mortgage Interest · Organization
Studer, Stanley
5% Or Greater Mortgage Interest · Individual
Threadgill, Forrest
5% Or Greater Mortgage Interest · Individual
Threadgill, Morgan
5% Or Greater Mortgage Interest · Individual
Threadgill, Sharlyn
Operational/Managerial Control · Individual
Threadgill, Sharlyn
5% Or Greater Mortgage Interest · Individual
Threadgill, Wade
5% Or Greater Mortgage Interest · Individual
Nearby options
Other facilities in reach
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#2
Crimson Heights Health & Wellness
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2-star overall rating with 2-star inspections with $16,996 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Deerbrook Skilled Nursing and Rehab Center
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1-star overall rating with 1-star inspections with $78,411 in total fines with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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