Cycle 1
Health 2024-12-12 · Fire 2024-12-12
6 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Katy, TX
Mason Creek Transitional Care Of Katy
3-star overall rating with 3-star inspections with $16,175 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
21727 Provincial Blvd, Katy, TX
(281) 717-1302
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
95
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2008-10-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.59
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,950
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.55
Baseline 21.57% · Performance 21.18% · Measure score 0.55 · Achievement 0.55 · Improvement 0.36
Healthcare-associated infections
7.32
Baseline 8.15% · Performance 5.68% · Measure score 7.32 · Achievement 7.20 · Improvement 7.32
Total nurse turnover
3.86
Baseline 55.13% · Performance 47.89% · Measure score 3.86 · Achievement 3.86 · Improvement 1.89
Adjusted total nurse staffing
0.75
Baseline 3.24 hours · Performance 3.29 hours · Measure score 0.75 · Achievement 0.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.33% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 15.31% · Lower 95% interval 8.9% |
| Discharge to community | 46.34% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 41.03% · Lower 95% interval 36.05% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 92.23% |
95.27%
3 pts worse
|
Numerator 95 · Denominator 103 |
| Falls with major injury | 0.97% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 103 |
| Discharge self-care score | 47.54% |
53.69%
6.1 pts worse
|
Numerator 29 · Denominator 61 |
| Discharge mobility score | 57.38% |
50.94%
6.4 pts better
|
Numerator 35 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 1.94% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 103 · Adjusted rate 1.47% |
| Healthcare-associated infections requiring hospitalization | 5.68% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 2.63% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 144 |
| Staff flu vaccination coverage | 11.05% |
42%
30.9 pts worse
|
Numerator 20 · Denominator 181 |
| Discharge function score | 55.74% |
56.45%
0.7 pts worse
|
Numerator 34 · Denominator 61 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 68.09% |
25.2%
42.9 pts better
|
Numerator 32 · Denominator 47 |
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 2.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
97.1%
0.1 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 98.8% · Q4 91.9% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.9%
0.9 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.3%
3.5 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 7.5% · Q3 4.7% · Q4 5.8% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
2.7%
0.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 5.0% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
3.3%
2.6 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.3% · Q3 3.8% · Q4 3.7% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
18.9%
7.8 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 12.0% · Q3 8.8% · Q4 11.1% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
10.8%
5.5 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.6% · Q3 3.2% · Q4 4.7% · 4Q avg 5.3% · 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 | 13.0% |
15.4%
2.4 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 3.0% · Q3 8.7% · Q4 13.7% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
16.1%
8.7 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 32.3% · Q3 24.3% · Q4 9.6% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
15.0%
2.7 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 13.4% · Q3 9.3% · Q4 10.3% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.2%
0.2 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 6.4% · Q3 2.1% · Q4 1.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
12.0%
0.7 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 11.8% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
88.0%
10.7 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
25.9%
2.6 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 31.6% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-10 · Fire 2023-11-10
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 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
2024-12-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-19
F · Potential for more than minimal harm
2023-11-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-11-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-10
E · Potential for more than minimal harm
2022-09-09
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-10-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-12
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 2025-01-10
D · Potential for more than minimal harm
2024-12-12
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 2025-01-10
D · Potential for more than minimal harm
2024-12-12
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-12
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 2025-01-10
D · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-12
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-01-10
J · Immediate jeopardy
2024-11-07
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 2024-11-10
J · Immediate jeopardy
2024-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-10
J · Immediate jeopardy
2024-09-25
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 2023-12-12
E · Potential for more than minimal harm
2023-11-10
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 2023-12-08
D · Potential for more than minimal harm
2023-11-10
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 2023-12-08
D · Potential for more than minimal harm
2023-11-10
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 2023-12-08
C · Minimal harm
2023-11-10
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-12-08
E · Potential for more than minimal harm
2022-09-09
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 2022-10-10
Penalties and ownership
What sits behind the stars
$8,021
2024-11-07
Fine
Fine · fine $8,021
Fine
$8,154
2024-09-25
Fine
Fine · fine $8,154
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Aho, Andrew
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Cane Island Healthcare, Inc
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Reininger, David
Operational/Managerial Control · Individual
Stratton, Charles
Corporate Officer · Individual
Nearby options
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Oakmont Healthcare and Rehabilitation Center of Ka
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2-star overall rating with 3-star inspections with $12,740 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Falcon Point Post Acute
Katy, TX
3-star overall rating with 4-star inspections with $19,684 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Solera at West Houston
Houston, TX
2-star overall rating with 1-star inspections with $114,536 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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