Cycle 1
Health 2025-04-30 · Fire 2025-04-30
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Houston, TX
North Houston Transitional Care
3-star overall rating with 3-star inspections with $11,508 in total fines with 3 fire-safety deficiencies in the latest cycle
9814 Grant Rd, Houston, TX
(281) 547-0123
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
70
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2017-10-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 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
0.31
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.25
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
3.80
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.11
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,557
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.97
Baseline 21.92% · Performance 20.71% · Measure score 1.97 · Achievement 1.56 · Improvement 1.97
Healthcare-associated infections
6.02
Baseline 11.36% · Performance 7.21% · Measure score 6.02 · Achievement 2.08 · Improvement 6.02
Total nurse turnover
0
Performance 73.81% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.63 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.85% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 309 · Observed rate 13.59% · Lower 95% interval 9.64% |
| Discharge to community | 55.97% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 335 · Observed rate 45.97% · Lower 95% interval 49.73% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 147 · Denominator 154 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 154 |
| Discharge self-care score | 27.59% |
53.69%
26.1 pts worse
|
Numerator 24 · Denominator 87 |
| Discharge mobility score | 43.68% |
50.94%
7.3 pts worse
|
Numerator 38 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 154 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 204 · Observed rate 8.82% · Lower 95% interval 5.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 133 |
| Staff flu vaccination coverage | 50.58% |
42%
8.6 pts better
|
Numerator 87 · Denominator 172 |
| Discharge function score | 36.78% |
56.45%
19.7 pts worse
|
Numerator 32 · Denominator 87 |
| Transfer of health information to provider | 89.66% |
95.95%
6.3 pts worse
|
Numerator 52 · Denominator 58 |
| Transfer of health information to patient | 93.62% |
96.28%
2.7 pts worse
|
Numerator 88 · Denominator 94 |
| Resident COVID-19 vaccinations up to date | 76% |
25.2%
50.8 pts better
|
Numerator 38 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
97.1%
1 pts worse
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 96.3% · Q3 95.7% · Q4 96.8% · 4Q avg 96.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.3% |
97.9%
8.6 pts worse
|
95.5%
6.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.3% |
| 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 80.0% |
2.7%
77.3 pts worse
|
11.4%
68.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 80.8% · Q3 78.3% · Q4 72.4% · 4Q avg 80.0% |
| 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 | 6.2% |
18.9%
12.7 pts better
|
19.6%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.0% · Q3 9.1% · Q4 7.1% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
10.8%
2.8 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · 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 | 2.6% |
15.4%
12.8 pts better
|
16.3%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
16.1%
10.4 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 10.0% · Q4 3.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.5%
0.7 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 0.0% · 4Q avg 1.2% · 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 | 20.2% |
15.0%
5.2 pts worse
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 4.4% · Q4 30.9% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
4.2%
2.9 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
89.7%
10.2 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.6% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
12.0%
0.3 pts better
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 12.1% · Expected 11.6% · 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 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
88.0%
7.1 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.9%
1.8 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 28.2% · Expected 27.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-03
F · Potential for more than minimal harm
2025-04-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-03
E · Potential for more than minimal harm
2025-04-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-03
E · Potential for more than minimal harm
2024-02-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-01
E · Potential for more than minimal harm
2022-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-28
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 2024-08-30
K · Immediate jeopardy
2024-08-20
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 2024-08-22
K · Immediate jeopardy
2024-08-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-08-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-08-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-07-02
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 2024-07-23
E · Potential for more than minimal harm
2024-02-22
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 2024-04-01
Penalties and ownership
What sits behind the stars
$11,508
2024-08-20
Fine
Fine · fine $11,508
Fine
Ownership
Mainstreeidence Developments LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Carnagie, Russell
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Phan, Hoang-Anh
Contracted Managing Employee · Individual
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Misty Willow Healthcare and Rehabilitation Center
Houston, TX
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $46,677 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Champions Healthcare At Willowbrook
Houston, TX
2-star overall rating with 2-star inspections with $31,270 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Fallbrook Rehabiliation and Care Center
Houston, TX
1-star overall rating with 1-star inspections with $173,479 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out