01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-08 | 6 | 2026-04-08 | 0 |
| Cycle 2 | 2025-01-30 | 19 | 2025-01-30 | 2 |
| Cycle 3 | 2023-12-07 | 5 | 2023-12-07 | 3 |
CMS CCN 6763812026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
West Houston Rehabilitation And Healthcare Center
13428 Bissonnet · Houston, TX 77083 · Harris County
Certified beds124CMS provider file
Recent citation rows35current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
35 rows in the current release
7 rows carry G–L scope/severity codes; 7 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-20 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2026-05-25 · complaint2026-04-08 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-08 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-08 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-08 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-04-10 · complaint2026-04-08 · HEALTHF0790Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
Correction field: Deficient, Provider has date of correction · 2026-04-102025-01-30 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-01-31 · complaint2025-01-30 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-30 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-02-012025-01-30 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-02-012024-12-31 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-01-01 · complaint2024-12-31 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-01-01 · complaint2024-12-31 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-01-01 · complaint2024-11-21 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-12-13 · complaint2024-10-25 · HEALTHF0580Severity J · isolated immediate jeopardy
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2024-10-26 · complaint2024-10-25 · HEALTHF0600Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-10-26 · complaint2024-10-25 · HEALTHF0607Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-10-26 · complaint2024-10-25 · HEALTHF0609Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-10-26 · complaint2024-10-25 · HEALTHF0610Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-10-26 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-10-25 | Fine | $182,988 | 0 |
| 2024-10-25 | Payment Denial | $0 | 9 |
| 2024-03-11 | Fine | $22,205 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- COMPTON3 HOLDINGS, LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2021
- MARTEL HEALTHCARE MANAGEMENT LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2021
- MISSION BEND HEALTHCARE INVESTMENTS, LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2021
- THE SMITHERS MANAGEMENT TRUSTOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2021
- COMPTON, CHARLESIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 09/17/2024
- COMPTON, JAMESIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 09/17/2024
- COMPTON, KRISIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 09/17/2024
- MARTEL, MICHAELIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 09/17/2024
- THOMPSON, JOHNNYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2024
- LTC OF WEST HOUSTON LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2021
- THREADGILL, SHARLYNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2021
- REED, MICHAELIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 04/02/2025
- REED, STACIEIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 04/02/2025
- THREADGILL, FORRESTIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/26/2025
- THREADGILL, MORGANIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/26/2025
- COMPTON3 HOLDINGS, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2021
- MARTEL HEALTHCARE MANAGEMENT LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2021
- MISSION BEND HEALTHCARE INVESTMENTS, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.26per resident day
RN hours0.24per resident day
Weekend nurse hours2.77per resident day
Staff turnover43.1%CMS reported field
06 / LOCAL RECORDS
Open the Houston ledger →Other published facilities nearby
Afton Oaks Nursing And Rehabilitation Center169 beds · CMS overall 1/544 citation rowsAshford Gardens202 beds · CMS overall 2/537 citation rowsAvir At Arden Wood174 beds · CMS overall 2/550 citation rowsAvir At Courtyard120 beds · CMS overall 4/526 citation rowsAvir At Golfcrest200 beds · CMS overall 2/532 citation rowsAvir At Houston148 beds · CMS overall 1/551 citation rowsAvir At Orem120 beds · CMS overall 4/537 citation rowsAvir At Veterans Memorial120 beds · CMS overall 1/538 citation rows