Cycle 1
Health 2025-01-08 · Fire 2025-01-08
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Mission, TX
Mission Nursing & Rehabilitation Center
5-star overall rating with 4-star inspections with $8,190 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1013 S Bryan Rd, Mission, TX
(281) 419-5520
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
170
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hmg Healthcare
Operator or chain grouping
Approved since
1988-07-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 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
0.49
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.52
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
3.09
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,215
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.57% · Performance 23.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.87
Baseline 5.60% · Performance 6.68% · Measure score 3.87 · Achievement 3.87 · Improvement 0
Total nurse turnover
3.19
Baseline 44.44% · Performance 50.63% · Measure score 3.19 · Achievement 3.19 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.40 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.42% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 15.66% · Lower 95% interval 8.21% |
| Discharge to community | 54.48% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 42.42% · Lower 95% interval 43.5% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 68.85% |
95.27%
26.4 pts worse
|
Numerator 42 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 54.05% |
53.69%
0.4 pts better
|
Numerator 20 · Denominator 37 |
| Discharge mobility score | 45.95% |
50.94%
5 pts worse
|
Numerator 17 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 61 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 91 |
| Staff flu vaccination coverage | 41.82% |
42%
0.2 pts worse
|
Numerator 69 · Denominator 165 |
| Discharge function score | 48.65% |
56.45%
7.8 pts worse
|
Numerator 18 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 100% |
25.2%
74.8 pts better
|
Numerator 29 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.3 · 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 | 1.3% |
3.3%
2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.4% · Q3 1.3% · Q4 1.4% · 4Q avg 1.3% · 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 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 4.9% |
18.9%
14 pts better
|
19.6%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.6% · Q3 3.0% · Q4 6.2% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
10.8%
5.6 pts worse
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 13.0% · Q3 14.3% · Q4 18.2% · 4Q avg 16.4% · 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 | 3.7% |
15.4%
11.7 pts better
|
16.3%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
16.1%
7.8 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 12.3% · Q3 7.1% · Q4 5.5% · 4Q avg 8.3% · 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 | 0.9% |
15.0%
14.1 pts better
|
19.8%
18.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.2% · Q4 1.3% · 4Q avg 0.9% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.2%
2.7 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.3% · Q3 1.8% · Q4 2.1% · 4Q avg 1.5% · 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 | 8.6% |
12.0%
3.4 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 8.9% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.5% · Q4 6.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
25.9%
1.2 pts better
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 24.4% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-06 · Fire 2023-10-06
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-28 · Fire 2022-07-28
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-08
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-03
B · Minimal harm
2025-01-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-03
E · Potential for more than minimal harm
2022-07-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-09-12
E · Potential for more than minimal harm
2022-07-28
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-09-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-03
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 2026-02-03
D · Potential for more than minimal harm
2025-01-08
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
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 2025-02-03
D · Potential for more than minimal harm
2025-01-08
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
2024-09-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-05-28
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-31
D · Potential for more than minimal harm
2023-12-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-30
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 2024-01-03
G · Actual harm
2023-10-06
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 2023-11-10
F · Potential for more than minimal harm
2023-10-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-06
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 2023-11-10
D · Potential for more than minimal harm
2023-10-06
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 2023-11-10
D · Potential for more than minimal harm
2023-10-06
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 2023-11-10
D · Potential for more than minimal harm
2023-10-06
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 2023-11-10
D · Potential for more than minimal harm
2022-07-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-28
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 2022-08-15
D · Potential for more than minimal harm
2022-07-28
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 2022-09-02
Penalties and ownership
What sits behind the stars
$8,190
2023-10-06
Fine
Fine · fine $8,190
Fine
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Culp, Roland
Operational/Managerial Control · Individual
Daspit, Laurence
Operational/Managerial Control · Individual
Guzman, Nefi
W-2 Managing Employee · Individual
Hmg Park Manor Of Mission, LLC
Operational/Managerial Control · Organization
Murrell, Edward
Corporate Officer · Individual
Norris, Sherrie
W-2 Managing Employee · Individual
Pico, Ana
Operational/Managerial Control · Individual
Prince, Derek
Operational/Managerial Control · Individual
Rollo, Jeffery
Operational/Managerial Control · Individual
Rollo, Jeffery
Corporate Officer · Individual
Stramecki, Anthony
Operational/Managerial Control · Individual
Stramecki, Anthony
Corporate Director · Individual
Vratis, Kacey
Operational/Managerial Control · Individual
Vratis, Kacey
Corporate Director · Individual
Way, George
Operational/Managerial Control · Individual
Way, George
Corporate Director · Individual
Way, George
Corporate Officer · Individual
Winnie-Stowell Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Mission Valley Nursing and Transitional Care
Mission, TX
3-star overall rating with 2-star inspections with $48,330 in total fines with 8 recent health deficiencies
#2
Village Healthcare and Rehabilitation
McAllen, TX
2-star overall rating with 2-star inspections with abuse icon flag with $28,970 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Briarcliff Nursing and Rehabilitation Center
McAllen, TX
1-star overall rating with 2-star inspections with abuse icon flag with $63,129 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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