Cycle 1
Health 2025-01-08 · Fire 2025-01-08
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Mont Belvieu, TX
Mont Belvieu Rehabilitation & Healthcare Center
1-star overall rating with 2-star inspections with $41,789 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
14000 Lakes Of Champions Blvd, Mont Belvieu, TX
(832) 669-3890
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2022-11-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.21
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.22
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,483
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.30% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 6.19% · Performance 8.75% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.29
Performance 46.15% · Measure score 4.29 · Achievement 4.29 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.52
Performance 3.23 hours · Measure score 0.52 · Achievement 0.52 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.52% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 128 · Observed rate 16.41% · Lower 95% interval 9.67% |
| Discharge to community | 46.61% |
50.57%
4 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 39.02% · Lower 95% interval 36.79% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.98% |
95.27%
2.7 pts better
|
Numerator 97 · Denominator 99 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 99 |
| Discharge self-care score | 65.52% |
53.69%
11.8 pts better
|
Numerator 38 · Denominator 58 |
| Discharge mobility score | 37.93% |
50.94%
13 pts worse
|
Numerator 22 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 2.02% |
2.29%
0.3 pts better
|
Numerator 2 · Denominator 99 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 8.75% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 92 · Observed rate 11.96% · Lower 95% interval 5.42% |
| Staff COVID-19 vaccination coverage | 6.29% |
8.2%
1.9 pts worse
|
Numerator 9 · Denominator 143 |
| Staff flu vaccination coverage | 12.44% |
42%
29.6 pts worse
|
Numerator 25 · Denominator 201 |
| Discharge function score | 53.45% |
56.45%
3 pts worse
|
Numerator 31 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 78.72% |
25.2%
53.5 pts better
|
Numerator 37 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.1
1.3 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.1%
2.3 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 2.6% · Q4 2.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
2.7%
1 pts worse
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 7.0% · Q3 1.4% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
3.3%
1.7 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 0.0% · Q4 1.4% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.9% |
18.9%
2 pts worse
|
19.6%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 20.9% · Q3 19.1% · Q4 20.5% · 4Q avg 20.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
10.8%
0.8 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.6% · Q3 11.1% · Q4 11.7% · 4Q avg 10.0% · 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 | 6.9% |
15.4%
8.5 pts better
|
16.3%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
16.1%
7.9 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 11.5% · Q3 8.2% · Q4 6.1% · 4Q avg 8.2% · 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 | 2.1% |
15.0%
12.9 pts better
|
19.8%
17.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.4% · Q4 5.1% · 4Q avg 2.1% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.2%
0.7 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.1% · Q3 5.7% · Q4 4.2% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
89.7%
6.3 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 94.7% · Q3 95.7% · Q4 96.9% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.2% |
12.0%
7.2 pts worse
|
12.0%
7.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 20.7% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
88.0%
10 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
25.9%
0.2 pts better
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 27.2% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-12 · Fire 2023-12-12
15 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-10-13 · Fire 2022-10-13
16 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · 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 2025-01-13
D · Potential for more than minimal harm
2025-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-08
F · Potential for more than minimal harm
2023-12-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-12-12
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 2024-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
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 2025-11-30
D · Potential for more than minimal harm
2025-11-20
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 2025-11-30
F · Potential for more than minimal harm
2025-01-08
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 2025-02-08
D · Potential for more than minimal harm
2025-01-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-02-08
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 2025-02-08
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 2025-02-08
D · Potential for more than minimal harm
2025-01-08
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-02-08
D · Potential for more than minimal harm
2024-12-10
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-12-10
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 2024-12-11
D · Potential for more than minimal harm
2024-09-24
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 2024-10-18
D · Potential for more than minimal harm
2024-02-08
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 2024-03-08
D · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-08
F · Potential for more than minimal harm
2023-12-12
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 2024-01-05
F · Potential for more than minimal harm
2023-12-12
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-12-12
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-12
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-12
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 2024-01-05
D · Potential for more than minimal harm
2023-12-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-12
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-05
C · Minimal harm
2023-12-12
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-01-05
B · Minimal harm
2023-12-12
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-28
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 2023-12-04
J · Immediate jeopardy
2023-10-04
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 2023-10-05
J · Immediate jeopardy
2023-10-04
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 2023-10-05
D · Potential for more than minimal harm
2023-10-04
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-10-05
J · Immediate jeopardy
2023-08-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-17
J · Immediate jeopardy
2023-08-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-17
J · Immediate jeopardy
2023-08-16
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 2023-08-17
F · Potential for more than minimal harm
2023-08-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-16
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 2023-08-17
K · Immediate jeopardy
2022-10-13
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-10-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-10-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-10-13
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 2022-10-14
D · Potential for more than minimal harm
2022-10-13
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 2022-10-14
Penalties and ownership
What sits behind the stars
$5,645
2024-02-06
Fine
Fine · fine $5,645
Fine
$21,626
2023-10-04
Fine
Fine · fine $21,626
Fine
$14,518
2023-08-16
Fine
Fine · fine $14,518
Fine
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Prince, Derek
5% Or Greater Indirect Ownership Interest · Individual
Mont Belvieu Rhc LLC
Operational/Managerial Control · Organization
Murrell, Edward
Corporate Director · Individual
Prince, Derek
Operational/Managerial Control · Individual
Roberts, Matthew
Operational/Managerial Control · Individual
Whatley, Darcy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Focused Care At Burnet Bay
Baytown, TX
3-star overall rating with 2-star inspections with $12,893 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Rollingbrook Rehabilitation And Healthcare Center
Baytown, TX
3-star overall rating with 4-star inspections with $23,676 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Focused Care at Allenbrook
Baytown, TX
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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