Houston, TX

Park Manor Of Cyfair

5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

11001 Crescent Moon Dr, Houston, TX

(281) 805-0359

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

114

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Hmg Healthcare

Operator or chain grouping

Approved since

2000-01-10

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

33 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

No

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.46

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.75

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.93

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.14

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.22

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.76

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.48

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

3.25

CMS adjusted total nurse staffing hours

Case-mix index

1.32

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

46%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,404

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.74

Composite VBP score used to determine payment impact.

Payment multiplier

0.9832

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.71

Baseline 19.60% · Performance 19.25% · Measure score 4.71 · Achievement 4.71 · Improvement 0.86

Healthcare-associated infections

2.44

Baseline 8.00% · Performance 7.12% · Measure score 2.44 · Achievement 2.40 · Improvement 2.44

Total nurse turnover

1.52

Baseline 53.93% · Performance 57.45% · Measure score 1.52 · Achievement 1.52 · Improvement 0

Adjusted total nurse staffing

0.82

Baseline 2.59 hours · Performance 3.01 hours · Measure score 0.82 · Achievement 0 · Improvement 0.82

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.14%	10.72% 1.4 pts worse	No Different than the National Rate · Eligible stays 84 · Observed rate 16.67% · Lower 95% interval 8.31%
Discharge to community	49.18%	50.57% 1.4 pts worse	No Different than the National Rate · Eligible stays 73 · Observed rate 38.36% · Lower 95% interval 38.74%
Medicare spending per beneficiary	1.05	1.02 About the same
Drug regimen review with follow-up	91.67%	95.27% 3.6 pts worse	Numerator 33 · Denominator 36
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 36
Discharge self-care score	59.09%	53.69% 5.4 pts better	Numerator 13 · Denominator 22
Discharge mobility score	59.09%	50.94% 8.2 pts better	Numerator 13 · Denominator 22
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 36 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.12%	7.12% About the same	No Different than the National Rate · Eligible stays 31 · Observed rate 9.68% · Lower 95% interval 4.28%
Staff COVID-19 vaccination coverage	47.76%	8.2% 39.6 pts better	Numerator 64 · Denominator 134
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	59.09%	56.45% 2.6 pts better	Numerator 13 · Denominator 22
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	90.91%	25.2% 65.7 pts better	Numerator 20 · Denominator 22

Quality measures

Resident outcomes and process scores

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	0.3%	3.3% 3 pts better	3.3% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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	1.6%	3.3% 1.7 pts better	5.4% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 1.2% · Q4 0.0% · 4Q avg 1.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.1%	18.9% 9.8 pts better	19.6% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.1% · Q3 9.9% · Q4 8.4% · 4Q avg 9.1%
Percentage of long-stay residents who received an antipsychotic medication	5.5%	10.8% 5.3 pts better	16.7% 11.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.1% · Q3 4.6% · Q4 5.7% · 4Q avg 5.5% · 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	12.1%	15.4% 3.3 pts better	16.3% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 12.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.4%	16.1% 4.7 pts better	14.9% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 16.9% · Q3 6.9% · Q4 9.2% · 4Q avg 11.4% · 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	0.9%	0.8% 0.1 pts worse	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	3.5%	15.0% 11.5 pts better	19.8% 16.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 1.1% · Q4 7.6% · 4Q avg 3.5%
Percentage of long-stay residents with pressure ulcers	6.5%	4.2% 2.3 pts worse	5.1% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.2% · Q3 9.3% · Q4 4.9% · 4Q avg 6.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.3%	89.7% 9.6 pts better	81.7% 17.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.5% · Q4 97.9% · 4Q avg 99.3%
Percentage of short-stay residents who had an outpatient emergency department visit	2.3%	12.0% 9.7 pts better	12.0% 9.7 pts better	Short Stay · 20240701-20250630 · Adjusted 2.3% · Observed 2.6% · Expected 12.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.2%	1.5% 1.3 pts better	1.6% 1.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.9%	88.0% 10.9 pts better	79.7% 19.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.4%	25.9% 0.5 pts worse	23.9% 2.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 31.6% · Expected 28.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-07 · Fire 2025-08-07

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 2 Health 2024-06-06 · Fire 2024-06-06

1 health deficiencies

Top issue: Resident Rights (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-04-25 · Fire 2023-04-25

5 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-07

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 2025-09-01

D · Potential for more than minimal harm 2025-08-07

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-09-01

F · Potential for more than minimal harm 2024-06-06

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-06-19

E · Potential for more than minimal harm 2023-04-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-05-05

E · Potential for more than minimal harm 2023-04-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-05-05

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-04-15

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 2025-05-09

E · Potential for more than minimal harm 2024-06-06

F584 · Resident Rights Deficiencies

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 2024-06-13

E · Potential for more than minimal harm 2023-04-25

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 2023-06-15

E · Potential for more than minimal harm 2023-04-25

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-06-15

E · Potential for more than minimal harm 2023-04-25

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 2023-06-15

E · Potential for more than minimal harm 2023-04-25

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-06-15

D · Potential for more than minimal harm 2023-04-25

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-06-15

Penalties and ownership