Cycle 1
Health 2025-10-07 · Fire 2025-10-07
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Houston, TX
West Janisch Health Care Center
1-star overall rating with 1-star inspections with abuse icon flag with $7,443 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
617 W Janisch St, Houston, TX
(713) 696-9093
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Health Services Management
Operator or chain grouping
Approved since
1995-10-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 3 overall / 3 health / 3 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
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,379
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.80% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.90
Performance 6.97% · Measure score 2.90 · Achievement 2.90 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Performance 70.49% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.12
Baseline 3.47 hours · Performance 3.68 hours · Measure score 2.12 · Achievement 2.12 · Improvement 0.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 16.67% · Lower 95% interval 7.63% |
| Discharge to community | 50.12% |
50.57%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 36.59% · Lower 95% interval 37.79% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.1% |
95.27%
1.8 pts better
|
Numerator 67 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 64.44% |
53.69%
10.8 pts better
|
Numerator 29 · Denominator 45 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 21 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 10.14% |
2.29%
7.9 pts worse
|
Numerator 7 · Denominator 69 · Adjusted rate 7.69% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 66 |
| Staff flu vaccination coverage | 51.85% |
42%
9.9 pts better
|
Numerator 42 · Denominator 81 |
| Discharge function score | 51.11% |
56.45%
5.3 pts worse
|
Numerator 23 · Denominator 45 |
| Transfer of health information to provider | 84.62% |
95.95%
11.3 pts worse
|
Numerator 22 · Denominator 26 |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 8 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
97.1%
8.6 pts worse
|
93.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 82.5% · Q3 82.1% · Q4 98.2% · 4Q avg 88.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
97.9%
1.1 pts worse
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.3%
2.4 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
2.7%
0.8 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
3.3%
3.4 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.8% · Q3 1.9% · Q4 15.1% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
18.9%
5.2 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 18.9% · Q3 11.1% · Q4 7.5% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
10.8%
2.1 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.5% · Q3 9.3% · Q4 12.5% · 4Q avg 8.7% · 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 | 26.9% |
15.4%
11.5 pts worse
|
16.3%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.6% |
16.1%
13.5 pts worse
|
14.9%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 14.3% · Q3 33.3% · Q4 36.6% · 4Q avg 29.6% · 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 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.0% |
15.0%
3 pts worse
|
19.8%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 11.3% · Q3 12.8% · Q4 30.5% · 4Q avg 18.0% |
| Percentage of long-stay residents with pressure ulcers | 11.8% |
4.2%
7.6 pts worse
|
5.1%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.0% · Q3 8.8% · Q4 6.5% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.6% |
89.7%
26.1 pts worse
|
81.7%
18.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.3% · Q2 44.3% · Q3 51.6% · Q4 81.4% · 4Q avg 63.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
12.0%
3.2 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 10.3% · Expected 13.1% · 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 | 67.8% |
88.0%
20.2 pts worse
|
79.7%
11.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
25.9%
1.3 pts better
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 31.0% · Expected 30.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2024-09-12
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-08-10 · Fire 2023-08-10
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
K · Immediate jeopardy
2025-10-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-11-08
K · Immediate jeopardy
2025-10-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-10-02
E · Potential for more than minimal harm
2025-10-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-02
E · Potential for more than minimal harm
2025-10-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-02
D · Potential for more than minimal harm
2025-10-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-08
E · Potential for more than minimal harm
2024-09-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-07
F · Potential for more than minimal harm
2023-08-10
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-08-14
Inspection history
Recent health citations
K · Immediate jeopardy
2025-10-07
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 2025-10-09
K · Immediate jeopardy
2025-10-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-09
E · Potential for more than minimal harm
2025-10-07
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-10-09
E · Potential for more than minimal harm
2025-10-07
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-10-07
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 2025-10-09
D · Potential for more than minimal harm
2025-10-07
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 2025-10-09
D · Potential for more than minimal harm
2025-10-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-10-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-10-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-10-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-10-07
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 2025-10-09
D · Potential for more than minimal harm
2025-10-07
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-10-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-09
C · Minimal harm
2025-10-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-09
D · Potential for more than minimal harm
2024-09-12
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 2024-10-07
D · Potential for more than minimal harm
2024-09-12
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 2024-10-07
E · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-08-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-10
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 2023-09-01
G · Actual harm
2023-08-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-08-02
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 2023-08-10
Penalties and ownership
What sits behind the stars
$0
2025-10-07
Payment Denial
Payment Denial · denial start 2025-11-07 · 1 days
1 day denial
$7,443
2023-08-02
Fine
Fine · fine $7,443
Fine
$0
2023-08-02
Payment Denial
Payment Denial · denial start 2023-08-31 · 1 days
1 day denial
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bavare, Arusha
Operational/Managerial Control · Individual
Health Services Management, Inc.
5% Or Greater Mortgage Interest · Organization
Hsmtx/Janisch-Houston, LLC
Operational/Managerial Control · Organization
Janisch-Houston Realty, LLC
5% Or Greater Mortgage Interest · Organization
Murrell, Edward
Corporate Director · Individual
Mustafa, Beverly
Operational/Managerial Control · Individual
White, Joshua
Operational/Managerial Control · Individual
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#2
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2-star overall rating with 1-star inspections with $61,825 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
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