Cycle 1
Health 2025-06-13 · Fire 2025-06-13
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
Park Manor of Cypress Station
1-star overall rating with 1-star inspections with $33,976 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
420 Lantern Bend Dr, Houston, TX
(832) 249-6500
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hmg Healthcare
Operator or chain grouping
Approved since
2003-07-03
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.94
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.60
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,128
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.96
Baseline 65.12% · Performance 59.77% · Measure score 0.96 · Achievement 0.96 · Improvement 0.83
Adjusted total nurse staffing
0.66
Baseline 2.58 hours · Performance 2.96 hours · Measure score 0.66 · Achievement 0 · Improvement 0.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.49% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 11.11% · Lower 95% interval 6.95% |
| Discharge to community | 55.81% |
50.57%
5.2 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 43.1% · Lower 95% interval 42.18% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 29 · Denominator 29 |
| Falls with major injury | 3.45% |
0.77%
2.7 pts worse
|
Numerator 1 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 29 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 63.11% |
8.2%
54.9 pts better
|
Numerator 77 · Denominator 122 |
| Staff flu vaccination coverage | 58% |
42%
16 pts better
|
Numerator 87 · Denominator 150 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| 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 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 3 · 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 | 4.6% |
3.3%
1.3 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.9% · Q3 5.1% · Q4 4.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
2.7%
1.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| 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 | 13.5% |
18.9%
5.4 pts better
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 12.5% · Q3 13.9% · Q4 13.9% · 4Q avg 13.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
10.8%
4.4 pts worse
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 17.0% · Q3 17.0% · Q4 16.9% · 4Q avg 15.2% · 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 | 4.3% |
15.4%
11.1 pts better
|
16.3%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 7.7% · Q3 0.0% · Q4 5.9% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
16.1%
11.8 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.9% · Q3 3.0% · Q4 4.5% · 4Q avg 4.3% · 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 | 1.9% |
15.0%
13.1 pts better
|
19.8%
17.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 1.2% · Q4 3.4% · 4Q avg 1.9% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.2%
0.8 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.7% · Q3 5.0% · Q4 3.3% · 4Q avg 5.0% · 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 | 13.4% |
12.0%
1.4 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 16.7% · Expected 13.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.4% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
25.9%
1.5 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 29.2% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
6 health deficiencies
Top issue: Environmental (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-17 · Fire 2023-03-17
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-13
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-06-13
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-06-14
E · Potential for more than minimal harm
2024-05-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-07
F · Potential for more than minimal harm
2023-03-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-24
F · Potential for more than minimal harm
2023-03-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-24
F · Potential for more than minimal harm
2023-03-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-24
C · Minimal harm
2023-03-17
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-04-24
Inspection history
Recent health citations
K · Immediate jeopardy
2025-06-13
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 2025-06-14
E · Potential for more than minimal harm
2025-06-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-06-13
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-06-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-06-13
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 2025-06-14
D · Potential for more than minimal harm
2025-06-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-06-13
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 2025-06-14
D · Potential for more than minimal harm
2025-06-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-14
F · Potential for more than minimal harm
2024-05-09
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 2024-06-07
D · Potential for more than minimal harm
2024-05-09
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 2024-06-07
D · Potential for more than minimal harm
2024-05-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-07
K · Immediate jeopardy
2023-09-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-27
K · Immediate jeopardy
2023-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-27
J · Immediate jeopardy
2023-09-25
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 2023-09-27
E · Potential for more than minimal harm
2023-09-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-09-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-03-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-03-17
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 2023-03-24
D · Potential for more than minimal harm
2023-03-17
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 2023-03-24
D · Potential for more than minimal harm
2023-03-17
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 2023-03-24
D · Potential for more than minimal harm
2023-03-17
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-03-24
Penalties and ownership
What sits behind the stars
$12,740
2025-06-13
Fine
Fine · fine $12,740
Fine
$21,236
2023-09-25
Fine
Fine · fine $21,236
Fine
Ownership
Culp, Roland
5% Or Greater Indirect Ownership Interest · Individual
Daspit, Laurence
5% Or Greater Indirect Ownership Interest · Individual
Prince, Derek
5% Or Greater Indirect Ownership Interest · Individual
Adelekan, Adebukola
Operational/Managerial Control · Individual
Balsamo, Krystal
Operational/Managerial Control · Individual
Cibc Bank Usa
5% Or Greater Direct Ownership Interest · Organization
Culp, Roland
Operational/Managerial Control · Individual
Daspit, Laurence
Operational/Managerial Control · Individual
Forvis Mazars Llp
5% Or Greater Direct Ownership Interest · Organization
Hmg Long Term Care, LLC
Operational/Managerial Control · Organization
Hmg Park Manor Of Cypress Station, L.l.c.
Operational/Managerial Control · Organization
Mitchell, Vincent
Operational/Managerial Control · Individual
Murrell, Edward
Operational/Managerial Control · Individual
Murrell, Edward
Corporate Officer · Individual
Pico, Ana
5% Or Greater Indirect Ownership Interest · Individual
Pico, Ana
Operational/Managerial Control · Individual
Prince, Derek
Operational/Managerial Control · Individual
Rollo, Jeffery
Operational/Managerial Control · Individual
Rollo, Jeffery
Corporate Officer · Individual
Sabra Health Care Reit Inc
Operational/Managerial Control · Organization
Stramecki, Anthony
Operational/Managerial Control · Individual
Stramecki, Anthony
Corporate Director · Individual
Vratis, Kacey
Operational/Managerial Control · Individual
Way, George
Operational/Managerial Control · Individual
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Zions Bancorporation
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
The Heights Of North Houston
Houston, TX
3-star overall rating with 3-star inspections with $39,207 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Paradigm Northwest
Houston, TX
1-star overall rating with 1-star inspections with $51,400 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Villa Toscana At Cypress Woods
Houston, TX
2-star overall rating with 2-star inspections with $37,827 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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