Cycle 1
Health 2025-05-30 · Fire 2025-05-30
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Houston, TX
Parkway Place
4-star overall rating with 3-star inspections with $45,741 in total fines with 2 recent health deficiencies
1321 Park Bayou Dr, Houston, TX
(281) 556-9200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Buckner Retirement Services
Operator or chain grouping
Approved since
1999-01-07
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 3 health / 4 staffing / 5 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
0.81
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.63
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,828
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.16
Baseline 23.90% · Performance 22.76% · Measure score 1.16 · Achievement 0 · Improvement 1.16
Healthcare-associated infections
0
Baseline 7.21% · Performance 7.90% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.99
Baseline 53.33% · Performance 47.37% · Measure score 3.99 · Achievement 3.99 · Improvement 1.59
Adjusted total nurse staffing
3.80
Baseline 4.36 hours · Performance 4.16 hours · Measure score 3.80 · Achievement 3.80 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.12% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 204 · Observed rate 13.24% · Lower 95% interval 8.69% |
| Discharge to community | 52.45% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 206 · Observed rate 46.6% · Lower 95% interval 45.95% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.35% |
95.27%
0.1 pts better
|
Numerator 82 · Denominator 86 |
| Falls with major injury | 1.16% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 86 |
| Discharge self-care score | 67.12% |
53.69%
13.4 pts better
|
Numerator 49 · Denominator 73 |
| Discharge mobility score | 35.62% |
50.94%
15.3 pts worse
|
Numerator 26 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 1.16% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 86 · Adjusted rate 1.07% |
| Healthcare-associated infections requiring hospitalization | 7.9% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 8.26% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 8.47% |
8.2%
0.3 pts better
|
Numerator 5 · Denominator 59 |
| Staff flu vaccination coverage | 85.45% |
42%
43.5 pts better
|
Numerator 47 · Denominator 55 |
| Discharge function score | 63.01% |
56.45%
6.6 pts better
|
Numerator 46 · Denominator 73 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 66 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 78.38% |
25.2%
53.2 pts better
|
Numerator 29 · Denominator 37 |
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 · 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 | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 5.0% · Q4 5.0% · 4Q avg 2.6% · 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 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.3%
1.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.1% |
18.9%
11.8 pts better
|
19.6%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
10.8%
10.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
16.1%
11.6 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · 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 · 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 · Q2 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 | 0.0% |
15.0%
15 pts better
|
19.8%
19.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
4.2%
2.4 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 7.7% · Q4 6.7% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
89.7%
10 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 99.3% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
12.0%
7.7 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 4.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
88.0%
10.6 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
25.9%
8.3 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 16.0% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-10 · Fire 2023-03-10
6 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-30
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 2025-06-16
D · Potential for more than minimal harm
2025-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-16
K · Immediate jeopardy
2024-09-24
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 2024-10-08
J · Immediate jeopardy
2024-09-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-08
J · Immediate jeopardy
2024-09-24
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2024-10-08
E · Potential for more than minimal harm
2024-04-05
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 2024-05-01
E · Potential for more than minimal harm
2024-04-05
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 2024-05-01
E · Potential for more than minimal harm
2024-04-05
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 2024-05-01
E · Potential for more than minimal harm
2024-04-05
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-01
E · Potential for more than minimal harm
2023-11-22
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 2023-12-15
D · Potential for more than minimal harm
2023-03-10
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-11
D · Potential for more than minimal harm
2023-03-10
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 2023-03-11
D · Potential for more than minimal harm
2023-03-10
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 2023-03-11
D · Potential for more than minimal harm
2023-03-10
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 2023-03-11
D · Potential for more than minimal harm
2023-03-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-11
Penalties and ownership
What sits behind the stars
$45,741
2024-09-24
Fine
Fine · fine $45,741
Fine
Ownership
Buckner Retirement Services Inc
5% Or Greater Direct Ownership Interest · Organization
Gentry, Jeffrey
Corporate Officer · Individual
Moore, Jessica
Operational/Managerial Control · Individual
Reyes, Albert
Corporate Officer · Individual
Robbins, Kenneth
Corporate Director · Individual
Nearby options
Other facilities in reach
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Continuing Care At Eagles Trace
Houston, TX
4-star overall rating with 4-star inspections with $22,486 in total fines with 5 recent health deficiencies with 2 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
Park Manor Of Westchase
Houston, TX
1-star overall rating with 1-star inspections with $109,932 in total fines with 10 recent health deficiencies
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