Cycle 1
Health 2025-09-17 · Fire 2025-09-17
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
League City, TX
The Heights of League City
1-star overall rating with 1-star inspections with $132,398 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2620 W Walker, League City, TX
(281) 309-5400
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
194
Certified beds
Average residents
124
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Touchstone Communities
Operator or chain grouping
Approved since
2007-09-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 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
0.15
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.16
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,807
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.35
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
3.56
Baseline 22.15% · Performance 20.07% · Measure score 3.56 · Achievement 2.93 · Improvement 3.56
Healthcare-associated infections
0
Baseline 5.47% · Performance 8.10% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 59.05% · Performance 62.16% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.58
Baseline 3.49 hours · Performance 3.24 hours · Measure score 0.58 · Achievement 0.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 15.19% · Lower 95% interval 7.89% |
| Discharge to community | 32.51% |
50.57%
18.1 pts worse
|
Worse than the National Rate · Eligible stays 54 · Observed rate 18.52% · Lower 95% interval 20.55% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.41% |
95.27%
3.1 pts better
|
Numerator 62 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 55.17% |
53.69%
1.5 pts better
|
Numerator 16 · Denominator 29 |
| Discharge mobility score | 51.72% |
50.94%
0.8 pts better
|
Numerator 15 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 6.35% |
2.29%
4.1 pts worse
|
Numerator 4 · Denominator 63 · Adjusted rate 4.33% |
| Healthcare-associated infections requiring hospitalization | 8.1% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 12.77% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 1270 |
| Discharge function score | 51.72% |
56.45%
4.7 pts worse
|
Numerator 15 · Denominator 29 |
| Transfer of health information to provider | 76.47% |
95.95%
19.5 pts worse
|
Numerator 26 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.8 |
2.1
1.7 pts worse
|
1.9
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 4.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.1
1.3 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 58.6% |
97.1%
38.5 pts worse
|
93.4%
34.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.7% · Q2 63.7% · Q3 53.2% · Q4 54.5% · 4Q avg 58.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.0% |
97.9%
12.9 pts worse
|
95.5%
10.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.0% · Q3 0.9% · Q4 1.8% · 4Q avg 1.6% · 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 · 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 | 2.0% |
3.3%
1.3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 2.3% · Q4 1.1% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
18.9%
2.8 pts better
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 18.4% · Q3 14.6% · Q4 10.9% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.8% |
10.8%
8 pts better
|
16.7%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 1.6% · Q3 1.4% · Q4 1.4% · 4Q avg 2.8% · 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 | 14.6% |
15.4%
0.8 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 12.2% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
16.1%
1 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 20.5% · Q3 10.5% · Q4 3.6% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.1% · Q3 0.9% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.0% |
15.0%
About the same
|
19.8%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 17.6% · Q3 10.7% · Q4 8.3% · 4Q avg 15.0% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
4.2%
2.9 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.0% · Q3 6.7% · Q4 6.5% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.3% |
89.7%
43.4 pts worse
|
81.7%
35.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 43.0% · Q3 44.8% · Q4 62.6% · 4Q avg 46.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
12.0%
3.4 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 10.6% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.7% |
88.0%
45.3 pts worse
|
79.7%
37 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.7% |
| 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 36.4% · Expected 33.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-21 · Fire 2024-08-21
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-17
E · Potential for more than minimal harm
2025-09-17
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-17
F · Potential for more than minimal harm
2024-08-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-15
E · Potential for more than minimal harm
2023-05-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-01
E · Potential for more than minimal harm
2023-05-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-01
E · Potential for more than minimal harm
2023-05-25
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-07-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-12-20
J · Immediate jeopardy
2025-07-10
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 2025-07-10
J · Immediate jeopardy
2025-03-07
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-03-08
K · Immediate jeopardy
2025-01-13
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 2025-01-18
K · Immediate jeopardy
2025-01-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-18
J · Immediate jeopardy
2025-01-13
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 2025-01-18
D · Potential for more than minimal harm
2025-01-13
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-08-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-08-21
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 2024-09-15
E · Potential for more than minimal harm
2024-08-21
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 2024-09-15
D · Potential for more than minimal harm
2024-08-21
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 2024-09-15
D · Potential for more than minimal harm
2024-08-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-21
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 2024-09-15
D · Potential for more than minimal harm
2024-08-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-15
K · Immediate jeopardy
2024-05-30
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 2024-06-21
D · Potential for more than minimal harm
2024-05-09
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 2024-05-31
G · Actual harm
2023-09-05
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 2023-09-28
D · Potential for more than minimal harm
2023-09-05
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 2023-09-28
D · Potential for more than minimal harm
2023-09-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-05-25
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-25
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 2023-07-01
D · Potential for more than minimal harm
2023-05-25
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 2023-07-01
D · Potential for more than minimal harm
2023-05-25
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 2023-07-01
C · Minimal harm
2023-05-25
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-07-01
Penalties and ownership
What sits behind the stars
$26,685
2025-07-10
Fine
Fine · fine $26,685
Fine
$24,622
2025-03-07
Fine
Fine · fine $24,622
Fine
$18,353
2025-01-13
Fine
Fine · fine $18,353
Fine
$55,278
2024-05-30
Fine
Fine · fine $55,278
Fine
$7,460
2023-09-05
Fine
Fine · fine $7,460
Fine
Ownership
Uvalde County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Apolinar, Adam
Corporate Officer · Individual
Lowe, Megan
Operational/Managerial Control · Individual
Touchstone Strategies - League City LLC
Operational/Managerial Control · Organization
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