Cycle 1
Health 2025-03-05 · Fire 2025-03-05
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Huntsville, TX
Mrc Creekside
5-star overall rating with 4-star inspections with 4 recent health deficiencies
1433 Veterans Memorial Parkway, Huntsville, TX
(936) 439-4700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Methodist Retirement Communities
Operator or chain grouping
Approved since
2003-04-03
CMS approved date
Coverage
Medicare + Medicaid
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
0.35
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.40
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.34
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
5.09
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.48
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
5.48
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,613
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9965
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.28
Baseline 22.31% · Performance 19.79% · Measure score 4.28 · Achievement 3.55 · Improvement 4.28
Healthcare-associated infections
2.32
Baseline 5.29% · Performance 7.14% · Measure score 2.32 · Achievement 2.32 · Improvement 0
Total nurse turnover
3.70
Baseline 52.86% · Performance 48.57% · Measure score 3.70 · Achievement 3.70 · Improvement 1.03
Adjusted total nurse staffing
7.11
Baseline 4.91 hours · Performance 5.1 hours · Measure score 7.11 · Achievement 7.11 · Improvement 1.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.5% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 7.09% · Lower 95% interval 6.21% |
| Discharge to community | 71.59% |
50.57%
21 pts better
|
Better than the National Rate · Eligible stays 113 · Observed rate 69.03% · Lower 95% interval 64.27% |
| 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 93 · Denominator 93 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge self-care score | 74.58% |
53.69%
20.9 pts better
|
Numerator 44 · Denominator 59 |
| Discharge mobility score | 47.46% |
50.94%
3.5 pts worse
|
Numerator 28 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 2.15% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 93 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 81 · Observed rate 6.17% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 5 · Denominator 85 |
| Staff flu vaccination coverage | 57.55% |
42%
15.5 pts better
|
Numerator 80 · Denominator 139 |
| Discharge function score | 71.19% |
56.45%
14.7 pts better
|
Numerator 42 · Denominator 59 |
| Transfer of health information to provider | 98.46% |
95.95%
2.5 pts better
|
Numerator 64 · Denominator 65 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 18.6% |
25.2%
6.6 pts worse
|
Numerator 8 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · 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 | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
2.7%
1.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
3.3%
4.7 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 8.0% · Q3 6.7% · Q4 13.6% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
18.9%
2.9 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 17.2% · Q3 16.7% · Q4 8.3% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
10.8%
3 pts worse
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 12.5% · Q3 17.4% · Q4 14.3% · 4Q avg 13.8% · 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 | 17.7% |
15.4%
2.3 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
16.1%
4.4 pts better
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 8.3% · Q3 3.6% · Q4 13.6% · 4Q avg 11.7% · 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 | 1.6% |
0.8%
0.8 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.1% |
15.0%
0.1 pts worse
|
19.8%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 10.9% · Q3 23.9% · Q4 7.3% · 4Q avg 15.1% |
| Percentage of long-stay residents with pressure ulcers | 9.5% |
4.2%
5.3 pts worse
|
5.1%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 10.6% · Q3 10.0% · Q4 5.7% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
89.7%
9.3 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.4% · Q3 99.2% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
12.0%
4.3 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 8.2% · Expected 11.9% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
88.0%
10.4 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
25.9%
5 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 22.4% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-21 · Fire 2024-02-21
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-11 · Fire 2023-01-11
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-05
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 2025-03-06
D · Potential for more than minimal harm
2025-03-05
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 2025-03-06
D · Potential for more than minimal harm
2025-03-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-03-05
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 2025-03-06
D · Potential for more than minimal harm
2025-01-14
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 2025-01-20
F · Potential for more than minimal harm
2024-02-21
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 2024-03-20
F · Potential for more than minimal harm
2024-02-21
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-21
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 2024-03-20
D · Potential for more than minimal harm
2024-02-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-21
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 2024-03-20
D · Potential for more than minimal harm
2024-02-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-20
F · Potential for more than minimal harm
2023-01-11
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 2023-02-09
E · Potential for more than minimal harm
2023-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-09
Penalties and ownership
What sits behind the stars
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
Conger, Dale
Corporate Director · Individual
Currie, Matthew
Corporate Officer · Individual
Gilts, Kip
Corporate Director · Individual
King, William
Corporate Director · Individual
Koerner, William
Corporate Director · Individual
Logan, James
Operational/Managerial Control · Individual
Malone-Wardley, Romonica
Corporate Director · Individual
Methodist Retirement Communities
5% Or Greater Direct Ownership Interest · Organization
Morgan, Richard
Corporate Director · Individual
Mrc Towncreek
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
Focused Care At Huntsville
Huntsville, TX
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Huntsville Health Care Center
Huntsville, TX
4-star overall rating with 4-star inspections with $21,645 in total fines with 8 recent health deficiencies
#3
Willis Nursing And Rehabilitation LP
Willis, TX
5-star overall rating with 5-star inspections with $7,443 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out