B
78/100FFIII Houston SNF Tenant LLC Inspection Report, Violations & Safety Grade (HOUSTON, Texas)
8580 WOODWAY DRIVE, HOUSTON, Texas 77063
Phone: 7139793777
CMS Overall:3/5
Overview & Bed Count
Certified Beds
92
Avg Residents/Day
73.3
Ownership
Non profit - Other
Provider Type
Medicare
County
Harris
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall3/5
Health3/5
Staffing4/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.21 | 0.44 | +0.77 |
| Total Nurse Hours per Resident per Day | 4.44 | 3.42 | +1.03 |
| CMS Staffing Rating | 4/5 | 1.9/5 | - |
| Nursing Staff Turnover | 33.3% | 50.8% | - |
Health Citation History
25 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-08-28 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2025-08-28 | 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. | E – Moderate Harm Potential |
| 2025-08-28 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-08-28 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-08-28 | 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. | D – Moderate Harm Potential |
| 2025-08-28 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-07-31 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E – Moderate Harm Potential |
| 2025-07-31 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2025-07-31 | 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. | D – Moderate Harm Potential |
| 2025-07-31 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-03-29 | 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. | J – Immediate Jeopardy |
| 2025-03-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J – Immediate Jeopardy |
| 2025-02-26 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2024-07-25 | 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. | E – Moderate Harm Potential |
| 2024-07-25 | Resident Assessment and Care Planning Deficiencies | Assure that each resident’s assessment is updated at least once every 3 months. | D – Moderate Harm Potential |
| 2024-07-25 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2024-02-01 | 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. | D – Moderate Harm Potential |
| 2024-02-01 | Quality of Life and Care Deficiencies | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D – Moderate Harm Potential |
| 2024-02-01 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-02-01 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2023-06-01 | Resident Assessment and Care Planning Deficiencies | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | E – Moderate Harm Potential |
| 2023-06-01 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2023-06-01 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | E – Moderate Harm Potential |
| 2023-06-01 | 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. | E – Moderate Harm Potential |
| 2023-06-01 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
Fire Safety Citation History
8 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-08-28 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-08-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | E – Moderate Harm Potential |
| 2024-07-25 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2023-06-01 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2023-06-01 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-06-01 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2023-06-01 | Smoke Deficiencies | Provide properly protected cooking facilities. | C – Minimal Harm Potential |
| 2023-06-01 | Miscellaneous Deficiencies | Meet Health Care Facilities Code mechanical requirements. | C – Minimal Harm Potential |
Total Penalties & Fines
$14,069
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-03-29 | Fine | $14,069 | - |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the HOUSTON area at no cost.
Find Safe, Vetted Facilities Near HOUSTON
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.