Cycle 1
Health 2025-05-29 · Fire 2025-05-29
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Corpus Christi, TX
Mirador
4-star overall rating with 4-star inspections with $22,922 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
5857 Timbergate Dr, Corpus Christi, TX
(361) 994-0905
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
41
Certified beds
Average residents
36
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Methodist Retirement Communities
Operator or chain grouping
Approved since
2011-12-29
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 4 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
0.78
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.47
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.91
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,277
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9935
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.01
Baseline 17.44% · Performance 20.04% · Measure score 3.01 · Achievement 3.01 · Improvement 0
Healthcare-associated infections
4.35
Baseline 5.31% · Performance 6.54% · Measure score 4.35 · Achievement 4.35 · Improvement 0
Total nurse turnover
3.86
Baseline 45.24% · Performance 47.92% · Measure score 3.86 · Achievement 3.86 · Improvement 0
Adjusted total nurse staffing
5.04
Baseline 5.02 hours · Performance 4.51 hours · Measure score 5.04 · Achievement 5.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 179 · Observed rate 7.82% · Lower 95% interval 7.34% |
| Discharge to community | 65.01% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 175 · Observed rate 65.14% · Lower 95% interval 57.06% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 72.9% |
95.27%
22.4 pts worse
|
Numerator 78 · Denominator 107 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 107 |
| Discharge self-care score | 53.75% |
53.69%
0.1 pts better
|
Numerator 43 · Denominator 80 |
| Discharge mobility score | 47.5% |
50.94%
3.4 pts worse
|
Numerator 38 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 1.87% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 107 · Adjusted rate 1.84% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 4.46% · Lower 95% interval 3.89% |
| Staff COVID-19 vaccination coverage | 6.94% |
8.2%
1.3 pts worse
|
Numerator 5 · Denominator 72 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 57.5% |
56.45%
1 pts better
|
Numerator 46 · Denominator 80 |
| Transfer of health information to provider | 93.75% |
95.95%
2.2 pts worse
|
Numerator 30 · Denominator 32 |
| Transfer of health information to patient | 94.12% |
96.28%
2.2 pts worse
|
Numerator 64 · Denominator 68 |
| Resident COVID-19 vaccinations up to date | 25.93% |
25.2%
0.7 pts better
|
Numerator 14 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
97.1%
1.5 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 100.0% · 4Q avg 98.6% |
| 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.3%
0.5 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.8% |
18.9%
11.9 pts worse
|
19.6%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
10.8%
10.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.6% |
16.1%
14.5 pts worse
|
14.9%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.6% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
0.8%
3.5 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.0% · 4Q avg 4.3% · 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 · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.2%
2.5 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 5.9% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
89.7%
1.7 pts worse
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 79.5% · Q3 87.0% · Q4 93.7% · 4Q avg 88.0% |
| 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 11.3% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
88.0%
About the same
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
25.9%
0.4 pts better
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 23.9% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-29 · Fire 2024-03-29
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-25
F · Potential for more than minimal harm
2023-01-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-25
D · Potential for more than minimal harm
2023-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-25
D · Potential for more than minimal harm
2023-01-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-29
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 2025-06-25
D · Potential for more than minimal harm
2025-05-29
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-29
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 2025-06-25
D · Potential for more than minimal harm
2025-04-29
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 2025-05-22
J · Immediate jeopardy
2025-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-07
J · Immediate jeopardy
2025-04-25
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 2024-09-07
E · Potential for more than minimal harm
2025-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-07
J · Immediate jeopardy
2024-05-25
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 2024-06-19
D · Potential for more than minimal harm
2024-05-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-10
F · Potential for more than minimal harm
2024-03-29
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 2024-04-13
D · Potential for more than minimal harm
2024-03-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-03-29
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 2024-04-13
D · Potential for more than minimal harm
2024-03-29
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 2024-04-13
D · Potential for more than minimal harm
2024-03-29
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 2024-04-13
D · Potential for more than minimal harm
2024-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-13
E · Potential for more than minimal harm
2023-01-12
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 2023-03-10
D · Potential for more than minimal harm
2023-01-12
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 2023-03-10
D · Potential for more than minimal harm
2023-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
$14,901
2025-04-25
Fine
Fine · fine $14,901
Fine
$8,021
2024-05-25
Fine
Fine · fine $8,021
Fine
Ownership
The Aldersgate Trust
5% Or Greater Indirect Ownership Interest · Organization
Baggett, Alyce
Corporate Director · Individual
Besser, Alicia
Corporate Director · Individual
Brown, Alan
Corporate Director · Individual
Brown, Alan
Corporate Officer · Individual
Bunch, James
Corporate Director · Individual
Childress, Charles
Operational/Managerial Control · Individual
Conger, Dale
Corporate Director · Individual
Currie, Matthew
Corporate Officer · Individual
Gilts, Kip
Corporate Director · Individual
Gonzales, Lisa
Operational/Managerial Control · Individual
King, William
Corporate Director · Individual
Koerner, William
Corporate Director · Individual
Malone-Wardley, Romonica
Corporate Director · Individual
Methodist Retirement Communities
5% Or Greater Direct Ownership Interest · Organization
Morgan, Richard
Corporate Director · Individual
Mrc Senior Living Corpus Christi
5% Or Greater Direct Ownership Interest · Organization
Partin, Todd
Operational/Managerial Control · Individual
Simmons, Ed
Corporate Director · Individual
Stephens, Donald
Corporate Officer · Individual
Thomas, Amy
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Mortgage Interest · Organization
Watson, Frankie
Corporate Director · Individual
Williamson, Billy
Corporate Director · Individual
Woodward, Walter
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Cimarron Place Health & Rehabilitation Center
Corpus Christi, TX
4-star overall rating with 4-star inspections with $10,033 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Corpus Christi Nursing And Rehabilitation Center
Corpus Christi, TX
2-star overall rating with 3-star inspections with $13,397 in total fines with 8 recent health deficiencies
#3
Wooldridge Place Nursing Center
Corpus Christi, TX
3-star overall rating with 3-star inspections with $90,880 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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