Cycle 1
Health 2025-01-30 · Fire 2025-01-30
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
West Houston Rehabilitation And Healthcare Center
1-star overall rating with 1-star inspections with $205,193 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
13428 Bissonnet, Houston, TX
(713) 351-4300
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Momentum Skilled Services
Operator or chain grouping
Approved since
2015-04-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.21
Registered nurse staffing
LPN hours / resident day
1.05
Licensed practical nurse staffing
Aide hours / resident day
1.80
Nurse aide staffing
Weekend hours
2.58
Weekend nurse staffing
RN turnover
70%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.9%
0.9 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.3%
2.1 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 2.2% |
3.3%
1.1 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
18.9%
8.4 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
10.8%
7 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.1% |
15.4%
0.3 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
16.1%
0.6 pts better
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.1% |
15.0%
5.9 pts better
|
19.8%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
4.2%
3.3 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
89.7%
4.9 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.5% |
12.0%
6.5 pts worse
|
12.0%
6.5 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
88.0%
4.6 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
25.9%
0.8 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-01
E · Potential for more than minimal harm
2025-01-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-01
F · Potential for more than minimal harm
2023-12-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-12-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-12-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-29
E · Potential for more than minimal harm
2022-09-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-30
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 2025-01-31
D · Potential for more than minimal harm
2025-01-30
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 2025-01-31
D · Potential for more than minimal harm
2025-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-30
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 2025-01-31
D · Potential for more than minimal harm
2025-01-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-30
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 2025-01-31
E · Potential for more than minimal harm
2024-12-31
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 2025-01-01
D · Potential for more than minimal harm
2024-12-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-01
D · Potential for more than minimal harm
2024-12-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-01
D · Potential for more than minimal harm
2024-11-21
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 2024-12-13
K · Immediate jeopardy
2024-10-25
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 2024-10-26
K · Immediate jeopardy
2024-10-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-26
K · Immediate jeopardy
2024-10-25
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 2024-10-26
K · Immediate jeopardy
2024-10-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-26
K · Immediate jeopardy
2024-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-26
J · Immediate jeopardy
2024-10-25
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 2024-10-26
E · Potential for more than minimal harm
2024-10-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-10-25
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 2024-10-26
J · Immediate jeopardy
2024-03-11
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 2024-03-28
E · Potential for more than minimal harm
2023-12-07
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 2023-12-29
E · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-07
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 2023-12-29
D · Potential for more than minimal harm
2023-12-07
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 2023-12-29
D · Potential for more than minimal harm
2023-06-16
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 2023-06-30
D · Potential for more than minimal harm
2022-09-29
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 2022-10-31
D · Potential for more than minimal harm
2022-09-29
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 2022-10-31
D · Potential for more than minimal harm
2022-09-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-31
Penalties and ownership
What sits behind the stars
$182,988
2024-10-25
Fine
Fine · fine $182,988
Fine
$0
2024-10-25
Payment Denial
Payment Denial · denial start 2024-12-04 · 9 days
9 day denial
$22,205
2024-03-11
Fine
Fine · fine $22,205
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Compton, Charles
5% Or Greater Mortgage Interest · Individual
Compton, James
5% Or Greater Mortgage Interest · Individual
Compton, Kris
5% Or Greater Mortgage Interest · Individual
Compton3 Holdings, LLC
5% Or Greater Mortgage Interest · Organization
Ltc Of West Houston LLC
Operational/Managerial Control · Organization
Martel Healthcare Management LLC
5% Or Greater Mortgage Interest · Organization
Martel, Michael
5% Or Greater Mortgage Interest · Individual
Mission Bend Healthcare Investments, LLC
5% Or Greater Mortgage Interest · Organization
The Smithers Management Trust
5% Or Greater Mortgage Interest · Organization
Thompson, Johnny
Corporate Officer · Individual
Threadgill, Sharlyn
Operational/Managerial Control · Individual
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#3
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3-star overall rating with 3-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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