Cycle 1
Health 2025-02-22 · Fire 2025-02-22
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Houston, TX
Park Manor Of Westchase
1-star overall rating with 1-star inspections with $109,932 in total fines with 10 recent health deficiencies
11910 Richmond Ave, Houston, TX
(281) 497-2838
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
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hmg Healthcare
Operator or chain grouping
Approved since
2005-08-09
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
0.75
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.19
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
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,760
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
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
1.69
Baseline 7.09% · Performance 7.33% · Measure score 1.69 · Achievement 1.69 · Improvement 0
Total nurse turnover
1.02
Baseline 69.56% · Performance 62.77% · Measure score 1.02 · Achievement 0 · Improvement 1.02
Adjusted total nurse staffing
0.48
Baseline 2.83 hours · Performance 3.12 hours · Measure score 0.48 · Achievement 0 · Improvement 0.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.71% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 16.39% · Lower 95% interval 8.25% |
| Discharge to community | 48.6% |
50.57%
2 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 41.18% · Lower 95% interval 35.72% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 92.86% |
95.27%
2.4 pts worse
|
Numerator 26 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | 71.43% |
53.69%
17.7 pts better
|
Numerator 15 · Denominator 21 |
| Discharge mobility score | 47.62% |
50.94%
3.3 pts worse
|
Numerator 10 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 10.91% |
8.2%
2.7 pts better
|
Numerator 12 · Denominator 110 |
| Staff flu vaccination coverage | 15% |
42%
27 pts worse
|
Numerator 21 · Denominator 140 |
| Discharge function score | 61.9% |
56.45%
5.4 pts better
|
Numerator 13 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
97.1%
2 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 91.9% · Q3 95.3% · Q4 95.6% · 4Q avg 95.1% |
| 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 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 who have depressive symptoms | 3.5% |
2.7%
0.8 pts worse
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 1.5% · Q3 2.7% · Q4 2.4% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 0.3% |
3.3%
3 pts better
|
5.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
18.9%
9.4 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 10.1% · Q3 9.2% · Q4 11.0% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
10.8%
5.6 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.1% · Q3 6.7% · Q4 9.0% · 4Q avg 5.2% · 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 | 6.2% |
15.4%
9.2 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.2% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
16.1%
4.9 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 18.8% · Q3 8.3% · Q4 10.4% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.3% |
15.0%
5.7 pts better
|
19.8%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 12.5% · Q3 7.6% · Q4 10.2% · 4Q avg 9.3% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.2%
0.7 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.7% · Q3 5.2% · Q4 3.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 36.6% |
89.7%
53.1 pts worse
|
81.7%
45.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 51.1% · Q3 43.0% · Q4 21.2% · 4Q avg 36.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
12.0%
0.6 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 14.7% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
88.0%
4 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
25.9%
0.3 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 29.4% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-22 · Fire 2023-12-22
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-06 · Fire 2022-10-06
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-12-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-12-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-31
E · Potential for more than minimal harm
2022-10-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-06-30
J · Immediate jeopardy
2025-02-22
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 2025-02-23
E · Potential for more than minimal harm
2025-02-22
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-02-22
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 2025-03-15
E · Potential for more than minimal harm
2025-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-15
D · Potential for more than minimal harm
2025-02-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-15
D · Potential for more than minimal harm
2025-02-22
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 2025-03-15
D · Potential for more than minimal harm
2025-02-22
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 2025-03-15
D · Potential for more than minimal harm
2025-02-22
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 2025-03-15
D · Potential for more than minimal harm
2025-02-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-15
D · Potential for more than minimal harm
2024-06-06
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 2024-07-08
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-01-31
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 2024-02-29
E · Potential for more than minimal harm
2023-12-22
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 2024-01-31
E · Potential for more than minimal harm
2023-12-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-22
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 2024-01-31
K · Immediate jeopardy
2023-09-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-26
J · Immediate jeopardy
2023-09-01
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 2023-09-08
J · Immediate jeopardy
2023-09-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-08
J · Immediate jeopardy
2023-09-01
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 2023-09-08
G · Actual harm
2023-09-01
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-09-01
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 2023-09-08
D · Potential for more than minimal harm
2023-09-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-09-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-24
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 2023-09-15
D · Potential for more than minimal harm
2023-08-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-15
D · Potential for more than minimal harm
2022-10-06
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 2022-10-21
D · Potential for more than minimal harm
2022-10-06
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 2022-10-21
Penalties and ownership
What sits behind the stars
$16,149
2025-02-22
Fine
Fine · fine $16,149
Fine
$93,783
2023-08-24
Fine
Fine · fine $93,783
Fine
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
Hill, Carrie
Operational/Managerial Control · Individual
Murrell, Edward
Operational/Managerial Control · Individual
Murrell, Edward
Corporate Officer · Individual
Odom, Tiffany
Operational/Managerial Control · Individual
Pico, Ana
5% Or Greater Indirect Ownership Interest · Individual
Pico, Ana
Operational/Managerial Control · Individual
Polio, Mayra
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
Sabra Health Care Reit Inc
5% Or Greater Direct Ownership Interest · 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
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West Oaks Nursing & Rehab Center
Houston, TX
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Avir at Houston
Houston, TX
2-star overall rating with 1-star inspections with $216,791 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Parkway Place
Houston, TX
4-star overall rating with 3-star inspections with $45,741 in total fines with 2 recent health deficiencies
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