Cycle 1
Health 2025-07-23 · Fire 2025-07-23
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
La Porte, TX
Sylan Shores Health and Wellness
1-star overall rating with 2-star inspections with abuse icon flag with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3950 Underwood Rd, La Porte, TX
(832) 861-6910
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
111
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Ml Healthcare
Operator or chain grouping
Approved since
2020-11-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 1 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
0.27
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.91
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.28
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
0.26
CMS adjusted RN staffing hours
Adjusted total hours
2.80
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,629
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.27% · Performance 22.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.35% · Performance 8.59% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.66
Baseline 66.67% · Performance 61.82% · Measure score 0.66 · Achievement 0 · Improvement 0.66
Adjusted total nurse staffing
0.41
Baseline 2.76 hours · Performance 3.04 hours · Measure score 0.41 · Achievement 0 · Improvement 0.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 11.63% · Lower 95% interval 7.41% |
| Discharge to community | 46.14% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 39.73% · Lower 95% interval 36.12% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 86.81% |
95.27%
8.5 pts worse
|
Numerator 79 · Denominator 91 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 91 |
| Discharge self-care score | 22.22% |
53.69%
31.5 pts worse
|
Numerator 10 · Denominator 45 |
| Discharge mobility score | 42.22% |
50.94%
8.7 pts worse
|
Numerator 19 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 1.1% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 91 · Adjusted rate 0.88% |
| Healthcare-associated infections requiring hospitalization | 8.59% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 12.73% · Lower 95% interval 4.22% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 170 |
| Staff flu vaccination coverage | 17.9% |
42%
24.1 pts worse
|
Numerator 41 · Denominator 229 |
| Discharge function score | 31.11% |
56.45%
25.3 pts worse
|
Numerator 14 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 2 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
97.1%
7.1 pts worse
|
93.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.8% · Q2 88.9% · Q3 100.0% · Q4 98.9% · 4Q avg 90.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
97.9%
About the same
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| 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 5.4% · Q2 4.4% · Q3 2.3% · Q4 1.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 0.0% · Q4 1.1% · 4Q avg 1.0% |
| 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 | 20.9% |
18.9%
2 pts worse
|
19.6%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 19.5% · Q3 19.7% · Q4 14.5% · 4Q avg 20.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
10.8%
0.8 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.4% · Q3 9.7% · Q4 13.0% · 4Q avg 10.0% · 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 · 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 | 8.3% |
15.4%
7.1 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
16.1%
3.2 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 14.1% · Q3 15.6% · Q4 13.4% · 4Q avg 12.9% · 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 | 18.3% |
15.0%
3.3 pts worse
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 24.2% · Q3 19.5% · Q4 7.2% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.2%
0.3 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.0% · Q3 4.4% · Q4 5.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.2% |
89.7%
31.5 pts worse
|
81.7%
23.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.6% · Q2 59.4% · Q3 65.8% · Q4 57.8% · 4Q avg 58.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
12.0%
4.4 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 19.7% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.9% · Q3 1.1% · Q4 3.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.0% |
88.0%
27 pts worse
|
79.7%
18.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.3% |
25.9%
5.4 pts worse
|
23.9%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 39.4% · Expected 30.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-13 · Fire 2023-04-13
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-13
E · Potential for more than minimal harm
2024-06-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-06-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-13
F · Potential for more than minimal harm
2023-04-13
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 2023-05-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-24
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 2025-12-19
J · Immediate jeopardy
2025-07-23
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 2025-07-17
E · Potential for more than minimal harm
2025-07-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-07-23
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 2025-08-08
D · Potential for more than minimal harm
2024-09-04
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 2024-09-27
D · Potential for more than minimal harm
2024-09-04
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 2024-09-27
D · Potential for more than minimal harm
2024-06-12
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-06-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-21
F · Potential for more than minimal harm
2023-04-13
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 2023-05-12
E · Potential for more than minimal harm
2023-04-13
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 2023-05-12
E · Potential for more than minimal harm
2023-04-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-13
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 2023-05-12
D · Potential for more than minimal harm
2023-04-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-13
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 2023-05-12
D · Potential for more than minimal harm
2023-04-13
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 2023-05-12
Penalties and ownership
What sits behind the stars
Ownership
Frio Hospital District
5% Or Greater Direct Ownership Interest · Organization
Langsdale, Troy
Operational/Managerial Control · Individual
Miller, Laura
Operational/Managerial Control · Individual
Ml - La Porte, LLC
Operational/Managerial Control · Organization
Mohammed, Shafraz
Operational/Managerial Control · Individual
Ruff, Michael
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Baywood Crossing Rehabilitation & Healthcare Cente
Pasadena, TX
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Courtyards At Pasadena
Pasadena, TX
3-star overall rating with 3-star inspections with $8,827 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Bay Ridge Healthcare Center
La Porte, TX
3-star overall rating with 3-star inspections with $18,054 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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