Cycle 1
Health 2025-01-30 · Fire 2025-01-30
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Odessa, TX
Madison Medical Resort
2-star overall rating with 3-star inspections with $32,445 in total fines with 3 recent health deficiencies
5001 Office Park Drive, Odessa, TX
(432) 362-1800
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foursquare Healthcare
Operator or chain grouping
Approved since
2013-12-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 4 health / 1 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
0.26
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.38
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
2.85
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
2.66
CMS adjusted total nurse staffing hours
Case-mix index
1.74
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,484
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.86% · Performance 22.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.71
Baseline 9.76% · Performance 7.75% · Measure score 3.71 · Achievement 0 · Improvement 3.71
Total nurse turnover
4.14
Baseline 46.15% · Performance 46.74% · Measure score 4.14 · Achievement 4.14 · Improvement 0
Adjusted total nurse staffing
0.24
Baseline 2.31 hours · Performance 2.56 hours · Measure score 0.24 · Achievement 0 · Improvement 0.24
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.38% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 179 · Observed rate 13.41% · Lower 95% interval 8.59% |
| Discharge to community | 43.79% |
50.57%
6.8 pts worse
|
No Different than the National Rate · Eligible stays 171 · Observed rate 36.26% · Lower 95% interval 36.91% |
| Medicare spending per beneficiary | 1.42 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.51% |
95.27%
4.2 pts better
|
Numerator 204 · Denominator 205 |
| Falls with major injury | 1.95% |
0.77%
1.2 pts worse
|
Numerator 4 · Denominator 205 |
| Discharge self-care score | 57.63% |
53.69%
3.9 pts better
|
Numerator 34 · Denominator 59 |
| Discharge mobility score | 49.15% |
50.94%
1.8 pts worse
|
Numerator 29 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 5 · Denominator 205 · Adjusted rate 1.73% |
| Healthcare-associated infections requiring hospitalization | 7.75% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 10% · Lower 95% interval 4.69% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 133 |
| Staff flu vaccination coverage | 47.79% |
42%
5.8 pts better
|
Numerator 65 · Denominator 136 |
| Discharge function score | 62.71% |
56.45%
6.3 pts better
|
Numerator 37 · Denominator 59 |
| Transfer of health information to provider | 98.85% |
95.95%
2.9 pts better
|
Numerator 86 · Denominator 87 |
| Transfer of health information to patient | 96.2% |
96.28%
0.1 pts worse
|
Numerator 76 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 0.86% |
25.2%
24.3 pts worse
|
Numerator 1 · Denominator 116 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 2.0 · 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 1.3 · Expected 1.4 · 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 | 5.2% |
3.3%
1.9 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.8% · Q3 2.4% · Q4 3.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 92.1% |
2.7%
89.4 pts worse
|
11.4%
80.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 92.9% · Q3 92.3% · Q4 90.5% · 4Q avg 92.1% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
3.3%
2.1 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.3% |
18.9%
5.4 pts worse
|
19.6%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 20.0% · Q3 27.3% · Q4 23.9% · 4Q avg 24.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
10.8%
0.7 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 11.3% · Q3 10.9% · Q4 7.9% · 4Q avg 10.1% · 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 | 20.7% |
15.4%
5.3 pts worse
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 22.0% · Q3 20.3% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
16.1%
4.1 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 16.1% · Q3 8.5% · Q4 15.2% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.5%
0.5 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.6% · Q4 1.0% · 4Q avg 1.0% · 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 | 22.1% |
15.0%
7.1 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 32.9% · Q3 23.0% · Q4 14.0% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
4.2%
3.7 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 9.5% · Q3 7.9% · Q4 5.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
89.7%
10 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
12.0%
1.6 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 8.6% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.6% · Q3 0.7% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
88.0%
9.6 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.4% |
25.9%
10.5 pts worse
|
23.9%
12.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.4% · Observed 31.7% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-11 · Fire 2022-10-11
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-03
K · Immediate jeopardy
2024-02-01
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 2024-02-02
K · Immediate jeopardy
2024-02-01
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 2024-02-02
E · Potential for more than minimal harm
2023-12-06
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 2024-01-05
D · Potential for more than minimal harm
2023-12-06
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 2024-01-05
D · Potential for more than minimal harm
2023-06-02
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 2023-07-02
E · Potential for more than minimal harm
2022-10-11
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 2022-11-10
E · Potential for more than minimal harm
2022-10-11
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 2022-11-10
D · Potential for more than minimal harm
2022-10-11
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-11-10
Penalties and ownership
What sits behind the stars
$32,445
2024-02-01
Fine
Fine · fine $32,445
Fine
Ownership
Midland County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bowerman, Stephen
Corporate Officer · Individual
Campbell Gs-Trust
5% Or Greater Mortgage Interest · Organization
Campbell, John
Operational/Managerial Control · Individual
Campbell, Kenneth
Operational/Managerial Control · Individual
Campbell, William
5% Or Greater Mortgage Interest · Individual
David W Miller Gs Trust
Operational/Managerial Control · Organization
Fairbrook Partners, LP
5% Or Greater Mortgage Interest · Organization
Jec Gs Trust
Operational/Managerial Control · Organization
Jem 5x5 Trust
5% Or Greater Mortgage Interest · Organization
John E Miller Gs Trust
Operational/Managerial Control · Organization
Kingsbury Capital LLC Series F
Operational/Managerial Control · Organization
Kjc Gs Trust
Operational/Managerial Control · Organization
Lewis, Shane
Operational/Managerial Control · Individual
Lion Plaza LP
Operational/Managerial Control · Organization
Miller Gs- Trust
5% Or Greater Mortgage Interest · Organization
Miller, David
Operational/Managerial Control · Individual
Miller, Don
5% Or Greater Mortgage Interest · Individual
Miller, John
Operational/Managerial Control · Individual
Miller, John
5% Or Greater Mortgage Interest · Individual
Miller, Richard
Operational/Managerial Control · Individual
Mnh-Inv Series LLC Series D
Operational/Managerial Control · Organization
Montague Nh, LP
5% Or Greater Mortgage Interest · Organization
Odessa Nh Realty, Ltd
5% Or Greater Mortgage Interest · Organization
Richard M Miller Gs Trust
Operational/Managerial Control · Organization
Sdl Gs 5x5 Trust
5% Or Greater Mortgage Interest · Organization
Uptown Fs LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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1-star overall rating with 2-star inspections with $8,724 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Parks Health Center
Odessa, TX
3-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Focused Care at Odessa
Odessa, TX
1-star overall rating with 2-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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