Cycle 1
Health 2025-04-30 · Fire 2025-04-30
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lake Jackson, TX
Oak Village Healthcare
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
204 Oak Drive South, Lake Jackson, TX
(979) 297-0425
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gulf Coast Ltc Partners
Operator or chain grouping
Approved since
2012-03-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 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
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.03
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
40%
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
3,842
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9954
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5
Baseline 20.00% · Performance 19.11% · Measure score 5 · Achievement 5 · Improvement 2.49
Healthcare-associated infections
5.63
Baseline 7.06% · Performance 6.15% · Measure score 5.63 · Achievement 5.63 · Improvement 3.91
Total nurse turnover
6.35
Baseline 69.39% · Performance 38.89% · Measure score 6.35 · Achievement 6.07 · Improvement 6.35
Adjusted total nurse staffing
0
Baseline 3.88 hours · Performance 2.91 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 10.42% · Lower 95% interval 7.28% |
| Discharge to community | 49.53% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 43.21% · Lower 95% interval 37.25% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 66 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 21 · Denominator 36 |
| Discharge mobility score | 41.67% |
50.94%
9.3 pts worse
|
Numerator 15 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 67 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.15% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 3.57% · Lower 95% interval 3.02% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 6.25% |
42%
35.8 pts worse
|
Numerator 6 · Denominator 96 |
| Discharge function score | 47.22% |
56.45%
9.2 pts worse
|
Numerator 17 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 2.7% |
25.2%
22.5 pts worse
|
Numerator 1 · Denominator 37 |
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 | 1.1 |
2.1
1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · 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 | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 5.0% · Q4 2.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
2.7%
4.3 pts worse
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 12.5% · Q3 2.5% · Q4 0.0% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
3.3%
4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 10.3% · Q3 10.0% · Q4 5.9% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.9% |
18.9%
11 pts better
|
19.6%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 13.3% · Q3 9.7% · Q4 0.0% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
10.8%
2.1 pts worse
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 12.5% · Q3 16.7% · Q4 13.3% · 4Q avg 12.9% · 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 | 17.5% |
15.4%
2.1 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.2% |
16.1%
10.9 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 11.1% · Q4 3.2% · 4Q avg 5.2% · 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 | 24.8% |
15.0%
9.8 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 32.9% · Q3 29.7% · Q4 26.6% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.2%
1.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.2% · Q3 0.0% · Q4 4.8% · 4Q avg 2.7% · 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 | 9.6% |
12.0%
2.4 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 11.5% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 3.7% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
88.0%
11.1 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.0% |
25.9%
4.1 pts worse
|
23.9%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.0% · Observed 37.7% · Expected 29.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-06 · Fire 2024-03-06
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-01
E · Potential for more than minimal harm
2025-04-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-01
E · Potential for more than minimal harm
2025-04-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-10
F · Potential for more than minimal harm
2024-03-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-03-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-22
E · Potential for more than minimal harm
2023-01-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-13
E · Potential for more than minimal harm
2023-01-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-13
C · Minimal harm
2023-01-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-04-30
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 2025-05-25
D · Potential for more than minimal harm
2025-04-30
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 2025-05-25
D · Potential for more than minimal harm
2024-03-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-03-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-26
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 2023-01-16
Penalties and ownership
What sits behind the stars
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bergeron, Bobby
Operational/Managerial Control · Individual
Murrell, Edward
Corporate Officer · Individual
Nicholson, Louis
Operational/Managerial Control · Individual
Oak Village Healthcare Ltc Partners, Inc
Operational/Managerial Control · Organization
Ovtx Real Estate Holdings, LLC
5% Or Greater Mortgage Interest · Organization
Pellerin, Richard
5% Or Greater Mortgage Interest · Individual
Nearby options
Other facilities in reach
#1
Brazos Healthcare Center
Lake Jackson, TX
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Creekside Village
Richwood, TX
4-star overall rating with 5-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Woodlake Nursing Center
Clute, TX
2-star overall rating with 3-star inspections with $20,965 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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