9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
1-star overall rating with 1-star inspections with $118,093 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
5201 S Willow Dr, Houston, TX
(713) 721-0297
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
148
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Paradigm Healthcare
Operator or chain grouping
Approved since
1996-07-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 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
RN hours / resident day
0.36
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
12,956
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 7.66% · Performance 8.68% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.83
Baseline 74.40% · Performance 57.89% · Measure score 2.83 · Achievement 1.42 · Improvement 2.83
Adjusted total nurse staffing
0
Baseline 3.12 hours · Performance 3.06 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 6.13% |
| Discharge to community | 34.39% |
50.57%
16.2 pts worse
|
Worse than the National Rate · Eligible stays 43 · Observed rate 16.28% · Lower 95% interval 22.36% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.14% |
95.27%
1.9 pts better
|
Numerator 34 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 35 · Adjusted rate 1.85% |
| Healthcare-associated infections requiring hospitalization | 8.68% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 20.69% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 30.99% |
42%
11 pts worse
|
Numerator 53 · Denominator 171 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 1.0% |
3.3%
2.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 1.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 lose too much weight | 5.9% |
3.3%
2.6 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 7.1% · Q3 4.5% · Q4 3.4% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.1% |
18.9%
13.8 pts better
|
19.6%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 3.1% · Q3 4.5% · Q4 3.4% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.5% |
10.8%
6.7 pts worse
|
16.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 18.8% · Q3 19.6% · Q4 10.0% · 4Q avg 17.5% · 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 | 16.1% |
15.4%
0.7 pts worse
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 0.0% · Q3 30.5% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
16.1%
0.3 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 19.3% · Q3 14.9% · Q4 13.7% · 4Q avg 15.8% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
15.0%
2.4 pts worse
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 16.5% · Q3 14.8% · Q4 10.5% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
4.2%
7.2 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 14.8% · Q3 10.4% · Q4 10.4% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
89.7%
5.2 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 78.5% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
12.0%
About the same
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 16.1% · Expected 15.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 3.0% · Q4 1.2% · 4Q avg 1.7% · 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 | 23.2% |
25.9%
2.7 pts better
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 32.3% · Expected 33.1% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-16
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-04-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-18
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-29
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-06
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-21
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-21
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-17
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-06
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-23
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-23
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-23
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-30
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-15
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-15
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-30
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-12
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-12
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 2024-06-12
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-02
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-02
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-07
Health
Have policies on smoking.
Corrected 2024-02-07
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-02-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-08
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-01-08
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-08
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-10
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 2023-11-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-08
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-24
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-09
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-10-21
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-21
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-21
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-10-21
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-21
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 2022-10-21
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-21
Health
Dispose of garbage and refuse properly.
Corrected 2022-10-21
Penalties and ownership
Fine · fine $22,455
Fine
Fine · fine $81,075
Fine
Fine · fine $14,563
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Nearby options
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3-star overall rating with 3-star inspections with $25,454 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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5-star overall rating with 5-star inspections with $57,184 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Houston, TX
4-star overall rating with 4-star inspections with $34,418 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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