Cycle 1
Health 2024-02-08 · Fire 2024-02-08
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Houston, TX
St Dominic Village Rehabilitation And Nursing Cent
5-star overall rating with 5-star inspections with $29,561 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2409 E Holcolm Blvd, Houston, TX
(713) 741-8701
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
158
Certified beds
Average residents
88
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-01-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.73
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.63
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.20
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.69
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
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,528
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.76
Baseline 18.83% · Performance 21.08% · Measure score 0.76 · Achievement 0.76 · Improvement 0
Healthcare-associated infections
0
Baseline 7.64% · Performance 10.03% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.43
Performance 53.76% · Measure score 2.43 · Achievement 2.43 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.83
Baseline 4.83 hours · Performance 4.45 hours · Measure score 4.83 · Achievement 4.83 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.52% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 124 · Observed rate 13.71% · Lower 95% interval 8.33% |
| Discharge to community | 52.66% |
50.57%
2.1 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 44.83% · Lower 95% interval 43.11% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 86 · Denominator 86 |
| Falls with major injury | 1.16% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 86 |
| Discharge self-care score | 69.39% |
53.69%
15.7 pts better
|
Numerator 34 · Denominator 49 |
| Discharge mobility score | 38.78% |
50.94%
12.2 pts worse
|
Numerator 19 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 86 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 10.03% |
7.12%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 14.67% · Lower 95% interval 6% |
| Staff COVID-19 vaccination coverage | 2.45% |
8.2%
5.7 pts worse
|
Numerator 5 · Denominator 204 |
| Staff flu vaccination coverage | 28.64% |
42%
13.4 pts worse
|
Numerator 59 · Denominator 206 |
| Discharge function score | 61.22% |
56.45%
4.8 pts better
|
Numerator 30 · Denominator 49 |
| Transfer of health information to provider | 88.24% |
95.95%
7.7 pts worse
|
Numerator 30 · Denominator 34 |
| Transfer of health information to patient | 97.44% |
96.28%
1.2 pts better
|
Numerator 38 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 95% |
25.2%
69.8 pts better
|
Numerator 38 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 48.9% |
97.1%
48.2 pts worse
|
93.4%
44.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.7% · Q2 50.0% · Q3 48.5% · Q4 48.3% · 4Q avg 48.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.8% |
97.9%
16.1 pts worse
|
95.5%
13.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.3%
0.4 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.3% · Q3 2.9% · Q4 1.7% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
2.7%
1.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
3.3%
6.9 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 8.3% · Q3 10.3% · Q4 7.8% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
18.9%
8.7 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 12.5% · Q3 8.2% · Q4 7.7% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.5% |
10.8%
4.3 pts better
|
16.7%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.1% · Q3 6.5% · Q4 5.6% · 4Q avg 6.5% · 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 | 14.1% |
15.4%
1.3 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
16.1%
7.1 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 9.1% · Q3 11.3% · Q4 8.9% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.5%
2.5 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.3% · Q3 4.2% · Q4 2.5% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
0.8%
1.1 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 4.7% · Q4 1.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.1% |
15.0%
3.9 pts better
|
19.8%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 14.4% · Q3 3.2% · Q4 9.5% · 4Q avg 11.1% |
| 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 · Q1 6.9% · Q2 6.2% · Q3 5.7% · Q4 7.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.8% |
89.7%
35.9 pts worse
|
81.7%
27.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.7% · Q2 61.5% · Q3 51.9% · Q4 48.7% · 4Q avg 53.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
12.0%
0.3 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 11.4% · Expected 10.4% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.4% |
88.0%
30.6 pts worse
|
79.7%
22.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.0% |
25.9%
4.1 pts worse
|
23.9%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.0% · Observed 27.1% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-09 · Fire 2022-12-09
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-09-23 · Fire 2021-09-23
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-26
E · Potential for more than minimal harm
2022-12-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-12-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-12-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-23
B · Minimal harm
2021-09-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-10-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-17
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 2026-01-12
D · Potential for more than minimal harm
2024-02-08
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-08
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 2024-03-06
D · Potential for more than minimal harm
2024-02-08
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 2024-03-06
D · Potential for more than minimal harm
2022-12-09
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-12-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-12-09
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 2022-12-27
D · Potential for more than minimal harm
2022-12-09
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 2022-12-27
E · Potential for more than minimal harm
2021-09-23
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 2021-10-15
E · Potential for more than minimal harm
2021-09-23
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 2021-10-15
D · Potential for more than minimal harm
2021-09-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-10-15
D · Potential for more than minimal harm
2021-09-23
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 2021-10-15
D · Potential for more than minimal harm
2021-09-23
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 2021-10-15
D · Potential for more than minimal harm
2021-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-15
Penalties and ownership
What sits behind the stars
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$11,645
2023-12-11
Fine
Fine · fine $11,645
Fine
$8,391
2023-11-06
Fine
Fine · fine $8,391
Fine
Ownership
St. Dominic Village
5% Or Greater Direct Ownership Interest · Organization
Badum, James
Corporate Director · Individual
Brooks, Richard
Corporate Director · Individual
Gibler, Linda
Corporate Director · Individual
Hotze, Bruce
Corporate Director · Individual
Idstein, Hugh
Corporate Director · Individual
Layne, Paul
Corporate Director · Individual
Makulski, Martin
Corporate Director · Individual
Mazzara, Ben
Corporate Director · Individual
Michalec, Rose
Corporate Director · Individual
Narcisse, Victor
Corporate Director · Individual
Parsley, Katherine
Corporate Director · Individual
Pelz, Lou
Corporate Director · Individual
Sam, Bryant
Operational/Managerial Control · Individual
Schriber, Lynn
Corporate Director · Individual
Sepe, Faith
Corporate Director · Individual
St. Dominic Village
Operational/Managerial Control · Organization
Todom Kuate, Vincent
Operational/Managerial Control · Individual
Tschirch, Poldi
Corporate Director · Individual
Wilson, Charles
Operational/Managerial Control · Individual
Wilson, Charles
Corporate Director · Individual
Wilson, Charles
Corporate Officer · Individual
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#3
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