Cycle 1
Health 2025-11-21 · Fire 2025-11-21
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
The Woodlands, TX
Park Manor Of The Woodlands
4-star overall rating with 4-star inspections with 6 recent health deficiencies
1014 Windsor Lake Boulevard, The Woodlands, TX
(936) 273-9424
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hmg Healthcare
Operator or chain grouping
Approved since
2011-02-17
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.65
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
0.13
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,659
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.85% · Performance 23.96% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.73% · Performance 8.10% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.59
Baseline 47.00% · Performance 44.91% · Measure score 4.59 · Achievement 4.59 · Improvement 0.44
Adjusted total nurse staffing
1.75
Baseline 3.45 hours · Performance 3.58 hours · Measure score 1.75 · Achievement 1.75 · Improvement 0.06
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.69% |
10.72%
3 pts worse
|
No Different than the National Rate · Eligible stays 463 · Observed rate 15.12% · Lower 95% interval 10.65% |
| Discharge to community | 51.23% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 451 · Observed rate 45.68% · Lower 95% interval 45.83% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.62% |
95.27%
3.4 pts better
|
Numerator 357 · Denominator 362 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 4 · Denominator 362 |
| Discharge self-care score | 55.02% |
53.69%
1.3 pts better
|
Numerator 137 · Denominator 249 |
| Discharge mobility score | 44.98% |
50.94%
6 pts worse
|
Numerator 112 · Denominator 249 |
| Pressure ulcers or injuries, new or worsened | 5.25% |
2.29%
3 pts worse
|
Numerator 19 · Denominator 362 · Adjusted rate 4.77% |
| Healthcare-associated infections requiring hospitalization | 8.1% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 300 · Observed rate 8.67% · Lower 95% interval 5.85% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 209 |
| Staff flu vaccination coverage | 24.41% |
42%
17.6 pts worse
|
Numerator 52 · Denominator 213 |
| Discharge function score | 51.41% |
56.45%
5 pts worse
|
Numerator 128 · Denominator 249 |
| Transfer of health information to provider | 98.29% |
95.95%
2.3 pts better
|
Numerator 115 · Denominator 117 |
| Transfer of health information to patient | 97.99% |
96.28%
1.7 pts better
|
Numerator 195 · Denominator 199 |
| Resident COVID-19 vaccinations up to date | 18.92% |
25.2%
6.3 pts worse
|
Numerator 35 · Denominator 185 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.1
1.3 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.2 · 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 | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.0% · Q3 3.6% · Q4 0.0% · 4Q avg 3.3% · 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 | 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 | 14.8% |
18.9%
4.1 pts better
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 13.8% · Q3 15.4% · Q4 18.5% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
10.8%
8.1 pts worse
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 16.0% · Q3 13.6% · Q4 18.2% · 4Q avg 18.9% · 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 | 0.0% |
15.4%
15.4 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
16.1%
10.5 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.4% · Q3 0.0% · Q4 14.8% · 4Q avg 5.6% · 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 | 6.1% |
15.0%
8.9 pts better
|
19.8%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 0.0% · Q3 11.1% · Q4 7.2% · 4Q avg 6.1% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.2%
3.3 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 0.9% · 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 99.8% · Q4 99.7% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
12.0%
5.1 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 7.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.7% |
88.0%
11.7 pts better
|
79.7%
20 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
25.9%
3.8 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 30.5% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-07-14 · Fire 2023-07-14
4 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-08-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-08-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-08-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-08-08
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 2024-08-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-21
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 2025-11-24
E · Potential for more than minimal harm
2025-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-24
D · Potential for more than minimal harm
2025-11-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-24
D · Potential for more than minimal harm
2025-11-21
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 2025-11-25
D · Potential for more than minimal harm
2025-11-21
F693 · Quality of Life and Care Deficiencies
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 2025-11-24
D · Potential for more than minimal harm
2025-11-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-24
D · Potential for more than minimal harm
2024-08-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-15
E · Potential for more than minimal harm
2023-07-14
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-14
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 2023-08-08
D · Potential for more than minimal harm
2023-07-14
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 2023-08-08
D · Potential for more than minimal harm
2023-07-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-08-08
Penalties and ownership
What sits behind the stars
Ownership
Balsamo, Krystal
Operational/Managerial Control · Individual
Cibc Bank Usa
5% Or Greater Direct Ownership Interest · Organization
Culp, Roland
5% Or Greater Indirect Ownership Interest · Individual
Culp, Roland
Operational/Managerial Control · Individual
Daspit, Laurence
5% Or Greater Indirect Ownership Interest · Individual
Daspit, Laurence
Operational/Managerial Control · Individual
Dohn, William
Operational/Managerial Control · Individual
Forvis Mazars Llp
5% Or Greater Direct Ownership Interest · Organization
Hmg Services LLC
5% Or Greater Direct Ownership Interest · Organization
Meghani, Ashrafali
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
5% Or Greater Indirect Ownership Interest · Individual
Prince, Derek
Operational/Managerial Control · Individual
Reinarz, Christian
Operational/Managerial Control · Individual
Rollo, Jeffery
Operational/Managerial Control · Individual
Rollo, Jeffery
Corporate Officer · Individual
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
Ridgewood at the Woodlands
The Woodlands, TX
1-star overall rating with 2-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Woodlands Nursing And Rehabilitation Center
The Woodlands, TX
3-star overall rating with 2-star inspections with $14,765 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Park Manor Of Conroe
Conroe, TX
5-star overall rating with 5-star inspections with $13,627 in total fines with 4 recent health deficiencies
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