7Risk Axes

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

How we calculate
SeverityElevated

85th national percentile — 11.8% high-severity citations

ChronicityLow

13th national percentile — 1 repeat citations

Staffing integrityClean

None on file

Fire safetyWatch

4 citations

Weekend staffing dropModerate

36th national percentile — 13.8%

Contract staff shareLow

17th national percentile — 0.0%

Clinical trendModerate

38th national percentile — 1/5 measures worsened

Staffing gapModerate

Reported 3.34 vs expected 3.34 · 0.00 hr/res/day

Recent Health Violations

Health inspection citations from official Medicare records

17 citations on file
F-0627
D
Ensure the transfer/discharge meets the resident's needs/preferences and…
Minimal Harm

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Survey date: Sep 4, 2025 · Isolated — no actual harm with potential for more
F-0644
D
Coordinate assessments with the pre-admission screening and resident rev…
Minimal Harm

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey date: Sep 4, 2025 · Isolated — no actual harm with potential for more
F-0880
E
Provide and implement an infection prevention and control program
Potential Harm

Provide and implement an infection prevention and control program.

Survey date: Mar 29, 2025 · Pattern — no actual harm with potential for more
F-0809
E
Ensure meals and snacks are served at times in accordance with resident’…
Potential Harm

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Survey date: Nov 7, 2024 · Pattern — no actual harm with potential for more

Recent Fire Safety Violations

Fire safety inspection citations from official Medicare records

4 citations on file
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: Nov 7, 2024 · Pattern — no actual harm with potential for more
F-0345
F
Have approved installation, maintenance and testing program for fire ala…
Potential Harm

Have approved installation, maintenance and testing program for fire alarm systems.

Survey date: Sep 1, 2023 · 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↻ Repeat

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

Survey date: Sep 1, 2023 · Pattern — no actual harm with potential for more
F-0712
F
Have simulated fire drills held at unexpected times
Potential Harm

Have simulated fire drills held at unexpected times.

Survey date: Sep 1, 2023 · Widespread — 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
MRC THE CROSSINGS
11.0 km · LEAGUE CITY, TX
★★★★★
CMS
21th
Risk %ile
Lower risk
HCA HOUSTON HEALTHCARE SOUTHEAST
14.8 km · PASADENA, TX
NR
CMS
25th
Risk %ile
Lower risk
Avir at Courtyard
21.1 km · Houston, TX
★★★
CMS
31th
Risk %ile
Lower risk