7Risk Axes

National percentile · lower = less risk · staffing gap is context only (not in composite)

How we calculate
SeverityLow

22th national percentile — 0.0% high-severity citations

ChronicityModerate

41th national percentile — 2 repeat citations

Staffing integrityClean

None on file

Fire safetyWatch

4 citations

Weekend staffing dropLow

25th national percentile — 12.3%

Contract staff shareWatch

59th national percentile — 2.1%

Clinical trendElevated

99th national percentile — 4/5 measures worsened

Staffing gapElevated

Reported 3.43 vs expected 3.93 · −0.50 hr/res/day

Recent Health Violations

Health inspection citations from official Medicare records

11 citations on file
F-0580
D
Immediately tell the resident, the resident's doctor, and a family membe…
Minimal Harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey date: Apr 10, 2026 · Isolated — no actual harm with potential for more
F-0583
D
Keep residents' personal and medical records private and confidential
Minimal Harm

Keep residents' personal and medical records private and confidential.

Survey date: Dec 1, 2025 · Isolated — no actual harm with potential for more
F-0677
D
Provide care and assistance to perform activities of daily living for an…
Minimal Harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey date: Dec 1, 2025 · Isolated — no actual harm with potential for more
F-0880
D
Provide and implement an infection prevention and control program
Minimal Harm

Provide and implement an infection prevention and control program.

Survey date: Dec 1, 2025 · Isolated — no actual harm with potential for more

Recent Fire Safety Violations

Fire safety inspection citations from official Medicare records

4 citations on file
F-0353
F
Inspect, test, and maintain automatic sprinkler systems
Potential Harm

Inspect, test, and maintain automatic sprinkler systems.

Survey date: Jun 19, 2025 · Widespread — no actual harm with potential for more
F-0741
F
Have posted "No-smoking" signs in areas where smoking is not permitted o…
Potential Harm

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Survey date: Jun 19, 2025 · Widespread — no actual harm with potential for more
F-0372
E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating…
Potential Harm

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Survey date: Apr 24, 2024 · Pattern — no actual harm with potential for more
F-0321
E
Ensure that special areas are constructed so that walls can resist fire …
Potential Harm

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Survey date: Feb 24, 2023 · Pattern — no actual harm with potential for more

Better Nearby Options

Within 25 km · sorted by overall risk percentile

Full nearby list
Facility
CMS
Risk %ile
Tier
Brazos Healthcare Center
3.3 km · Lake Jackson, TX
★★★
CMS
41th
Risk %ile
Similar risk
OAK VILLAGE HEALTHCARE
5.4 km · LAKE JACKSON, TX
★★★★★
CMS
43th
Risk %ile
Similar risk