Cycle 1
Health 2025-02-13 · Fire 2025-02-13
7 health deficiencies
Top issue: Environmental (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Houston, TX
Memorial City Nursing And Rehabilitation Center
2-star overall rating with 2-star inspections with $64,398 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1341 Blalock, Houston, TX
(713) 468-7821
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
187
Certified beds
Average residents
132
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2010-09-28
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
0.26
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.25
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
1.14
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,461
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.92
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
0.69
Baseline 20.67% · Performance 21.11% · Measure score 0.69 · Achievement 0.69 · Improvement 0
Healthcare-associated infections
0
Baseline 5.82% · Performance 8.07% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 53.98% · Performance 65.35% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.28
Baseline 4.03 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.07% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 14.96% · Lower 95% interval 8.64% |
| Discharge to community | 49.43% |
50.57%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 40.77% · Lower 95% interval 40.84% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 105 · Denominator 105 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 105 |
| Discharge self-care score | 63.41% |
53.69%
9.7 pts better
|
Numerator 52 · Denominator 82 |
| Discharge mobility score | 46.34% |
50.94%
4.6 pts worse
|
Numerator 38 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 0.95% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 105 · Adjusted rate 0.69% |
| Healthcare-associated infections requiring hospitalization | 8.07% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 11.39% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | 48.48% |
42%
6.5 pts better
|
Numerator 112 · Denominator 231 |
| Discharge function score | 59.76% |
56.45%
3.3 pts better
|
Numerator 49 · Denominator 82 |
| 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 | 78.72% |
96.28%
17.6 pts worse
|
Numerator 37 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 2.78% |
25.2%
22.4 pts worse
|
Numerator 1 · Denominator 36 |
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 100.0% · Q2 98.9% · Q3 99.0% · Q4 97.2% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
97.9%
1.1 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.2% · Q3 1.9% · Q4 0.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
3.3%
0.6 pts worse
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.6% · Q3 4.2% · Q4 6.1% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.4% |
18.9%
17.5 pts better
|
19.6%
18.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.0% |
10.8%
6.8 pts better
|
16.7%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.1% · Q3 1.8% · Q4 1.6% · 4Q avg 4.0% · 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 | 15.5% |
15.4%
0.1 pts worse
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 17.9% · Q3 26.1% · Q4 6.0% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
16.1%
0.9 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 5.7% · Q3 21.7% · Q4 15.1% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · 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 | 13.4% |
15.0%
1.6 pts better
|
19.8%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 4.8% · Q3 18.2% · Q4 10.7% · 4Q avg 13.4% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.2%
1.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.7% · Q3 4.0% · Q4 3.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
89.7%
8.5 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.6% · Q3 95.4% · Q4 96.8% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
12.0%
6.6 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.2% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
88.0%
9.8 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| 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 25.9% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-15 · Fire 2023-12-15
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-23 · Fire 2022-09-23
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-02-13
K913 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
Corrected 2025-02-17
F · Potential for more than minimal harm
2023-12-15
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-12-18
F · Potential for more than minimal harm
2023-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-12-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-18
E · Potential for more than minimal harm
2022-09-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-01
E · Potential for more than minimal harm
2022-09-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-01
E · Potential for more than minimal harm
2022-09-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-19
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 2025-11-20
D · Potential for more than minimal harm
2025-11-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-11-20
E · Potential for more than minimal harm
2025-07-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-02-13
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-02-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-24
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-27
D · Potential for more than minimal harm
2025-01-24
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 2025-01-27
G · Actual harm
2025-01-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-18
K · Immediate jeopardy
2024-09-23
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 2024-09-26
K · Immediate jeopardy
2024-09-23
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 2024-09-26
E · Potential for more than minimal harm
2024-09-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-23
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-07-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-31
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-08-05
J · Immediate jeopardy
2024-05-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-20
E · Potential for more than minimal harm
2023-12-15
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 2024-01-03
E · Potential for more than minimal harm
2023-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-15
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 2024-01-03
D · Potential for more than minimal harm
2023-12-15
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 2024-01-03
E · Potential for more than minimal harm
2023-11-21
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 2023-11-24
E · Potential for more than minimal harm
2023-10-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-16
E · Potential for more than minimal harm
2022-09-23
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-11-01
E · Potential for more than minimal harm
2022-09-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-09-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-09-23
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 2022-11-01
D · Potential for more than minimal harm
2022-09-23
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 2022-11-01
D · Potential for more than minimal harm
2022-09-23
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 2022-11-01
Penalties and ownership
What sits behind the stars
$21,057
2025-01-15
Fine
Fine · fine $21,057
Fine
$22,376
2024-09-23
Fine
Fine · fine $22,376
Fine
$20,965
2024-05-19
Fine
Fine · fine $20,965
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Carruth, Susan
Corporate Officer · Individual
Dekowski, Donovan
Operational/Managerial Control · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Noble, Cassandra
Operational/Managerial Control · Individual
Oakbend Medical Center
Operational/Managerial Control · Organization
Regency Ihs Of Memorial City LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
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