Cambridge Health and Rehabilitation Center
1106 Golfview, Richmond, TX 77469 · Fort Bend County · 158 certified beds · avg 120 residents/day · certified since Sep 27, 2001
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Feb 1, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 8, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Sep 29, 2023 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Sep 30, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 29, 2023 · F-0726 · triggered by a complaint
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 30, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 30, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 6, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 26, 2026 · F-0656 · triggered by a complaint
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 3, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 26, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 3, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 10, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 11, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (26)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 26, 2026 | ▲ G · Actual harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Feb 26, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 26, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 23, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| May 15, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 15, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Apr 3, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 10, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Mar 14, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 14, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 14, 2024 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. · from a complaint |
| Mar 14, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 1, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Sep 29, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Sep 29, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 30, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 24, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (4 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 3 | K ▲ |
| 2024 | 5 | 1 | K ▲ |
| 2025 | 6 | 1 | G ▲ |
| 2026 | 7 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $68,342.
| Date | Type | Amount / length |
|---|---|---|
| Jan 10, 2025 | Fine | $18,821 |
| Feb 1, 2024 | Fine | $16,448 |
| Aug 30, 2023 | Fine | $13,397 |
| Aug 30, 2023 | Fine | $19,676 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.21 | 3.46 | 3.95 | bottom 40% in Texas; bottom 22% in the U.S. |
| Registered Nurse hours | 0.43 | 0.44 | 0.69 | top 41% in Texas; bottom 26% in the U.S. |
| Weekend total nurse staffing | 2.92 | 3.04 | 3.50 | top 49% in Texas; bottom 27% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.31 | 0.34 | 0.48 | top 46% in Texas; bottom 33% in the U.S. |
| Total nursing staff turnover (%) | 40.6 | 55.3 | 45.8 | top 22% in Texas; top 38% in the U.S. |
| RN turnover (%) | 29.4 | 54.6 | 42.9 | top 18% in Texas; top 28% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.24, RN 0.43, weekend 2.95. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Oakbend Medical Center | Organization | 5% or Greater Direct Ownership Interest | 100% | 02/23/2015 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 02/23/2015 |
| Caretrust GP LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/23/2015 |
| Caretrust Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 02/23/2015 |
| Ctr Partnership LP | Organization | ADP of the SNF | NOT APPLICABLE | 02/23/2015 |
| Eapen, Sheila | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/23/2015 |
| Eapen, Sheila | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/23/2015 |
| Eapen, Sheila | Individual | ADP of the SNF | NOT APPLICABLE | 02/23/2015 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/07/2009 |
| Freudenberger, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 06/19/2007 |
| Golfview Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/23/2015 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Richmond Senior Services, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/23/2015 |
| Richmond Senior Services, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 10/17/2025 |
| Solipuram, Arun Kumar | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2019 |
| Solipuram, Arun Kumar | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2019 |
| Solipuram, Arun Kumar | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Richmond Health Care Center | 1.2 mi | Richmond, TX | ★★★★☆ | 4/5 | |
| Oak Bend Medical Center | 1.2 mi | Richmond, TX | ★★★★☆ | 4/5 | |
| Rosenberg Health & Rehabilitation Center | 2.0 mi | Rosenberg, TX | ★☆☆☆☆ | 1/5 | |
| Paradigm at the Brazos | 2.0 mi | Richmond, TX | ★★★★★ | 5/5 | |
| Fort Bend Healthcare Center | 4.2 mi | Rosenberg, TX | ★★★☆☆ | 3/5 | |
| Ignite Medical Resort Sugar Land, LLC | 7.0 mi | Sugar Land, TX | ★☆☆☆☆ | 2/5 | |
| The Crescent | 7.8 mi | Sugar Land, TX | ★☆☆☆☆ | 1/5 | |
| Sugar Land Health Care Center | 8.1 mi | Sugar Land, TX | ★★★☆☆ | 3/5 | |
| Paradigm at First Colony | 11.0 mi | Missouri City, TX | ★☆☆☆☆ | 1/5 | |
| Chelsea Gardens | 11.2 mi | Missouri City, TX | ★☆☆☆☆ | 2/5 | |
| West Houston Rehabilitation and Healthcare Center | 11.7 mi | Houston, TX | ★☆☆☆☆ | 1/5 | |
| Park Manor of Quail Valley | 11.7 mi | Missouri City, TX | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675901.