Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trend Health And Rehab Of Houston during CMS and state inspections, most recent first.
A resident with Parkinson's Disease and moderate cognitive deficits was made to go to bed by a CNA against her wishes, despite repeatedly expressing her desire to stay up and socialize. The CNA stated she had other work to do and did not respect the resident's preference, which was witnessed and reported by the roommate and confirmed by an RN. Facility policy requires support of resident choice, which was not followed in this instance.
A resident's call light was found to be inaccessible on two occasions, preventing her from requesting assistance. The CNA assigned to the resident acknowledged the issue, and the DON confirmed that the call light should be within reach.
The facility failed to honor a resident's preference for end-of-life Advance Directives. The resident had initially chosen a full code status, but a hospice form signed by the resident's daughter changed it to DNR without the resident's knowledge or consent. The resident was not informed of this change, and the facility did not have paperwork confirming the daughter as the POA.
The facility failed to notify a resident's physician of a significant skin concern. The resident had an excessive buildup on the scalp and beard, which was not documented or treated. Staff responsible for skin audits did not report the issue, and the Director of Nursing confirmed the oversight.
A facility failed to ensure privacy for a resident by changing the resident's brief next to an uncovered window. The resident, who has Huntington's disease and moderately impaired cognitive skills, expressed a desire for curtains. The CNA confirmed the window had been without a covering for some time, and the Administrator acknowledged the privacy issue.
The facility failed to complete a Comprehensive Admission MDS assessment within fourteen days for a resident. The assessment was left open and unsigned by an RN, and the MDS Nurse confirmed it was overlooked. The DON was unaware of the incomplete assessment and confirmed it should have been completed per RAI guidelines.
The facility failed to accurately complete MDS assessments for two residents with upper body contractures. One resident had a contracted left hand and fingers, while another had paralysis and contractures in the left arm and fingers. Both assessments incorrectly indicated no impairment in the range of motion of upper extremities, as admitted by the MDS RN and confirmed by the DON.
The facility failed to develop and implement comprehensive care plans for five residents, leading to unmet care needs. Observations revealed poor oral hygiene, improper medication administration, neglected nail care, and lack of prescribed devices. Interviews with the DON and MDS nurses confirmed these deficiencies.
A facility failed to follow professional standards for administering medications through a PEG tube for a resident with severe cognitive impairment. An LPN crushed and administered multiple medications together without using flushes and gravity, contrary to the physician's order. The facility lacked a current policy on PEG tube medication administration, leading to the LPN misreading the order.
The facility failed to provide appropriate oral care, nail care, and shaving for four residents, leading to issues such as crusty lips, long fingernails, and unshaved facial hair. Staff and the DON confirmed these deficiencies, acknowledging the need for consistent care as per facility policies.
A resident with chronic systolic heart failure, type 2 diabetes, vitamin D deficiency, and paroxysmal atrial fibrillation was found with an untreated skin concern involving a thick layer of white buildup and flaking on the scalp and beard. Staff interviews and record reviews revealed that the issue was not documented or reported, and no treatment orders were in place.
A resident with a contracture did not have a prescribed hand roll applied during waking hours on two observed occasions. The LPN and DON confirmed the aides were responsible for applying the hand roll, and the nurses were to ensure it was in place. The facility's policy on splint and brace application was not followed.
The facility failed to maintain a medication error rate below five percent, resulting in a 21.88% error rate. An LPN administered multiple medications through a PEG tube without following the physician's order to give each medication individually with a flush between each. The DON confirmed the error, and the LPN admitted to misreading the order. The resident involved had severe cognitive impairment and multiple medical diagnoses.
The facility failed to ensure proper medication storage by leaving keys for the medication cart, medication room, and controlled medication locked box unattended on the medication cart in the resident hallway. The LPN responsible acknowledged the risk, and the DON confirmed the lapse. The facility lacked a policy for medication storage.
A nurse in an LTC facility dropped a glove on the floor, picked it up, and continued with medication administration without changing the glove or washing her hands again. The DON confirmed that proper infection control techniques were not followed, increasing the likelihood of infection spread. The resident involved had multiple diagnoses, including diabetes and COPD.
The facility failed to provide the Notice of Medicare Non-Coverage to two residents discharged from Medicare Part A services with service times remaining. The Administrator acknowledged the requirement but admitted it was not being done due to staff turnover and oversight. This deficiency was identified during a review of facility records and staff interviews.
Resident's Bedtime Choice Not Honored by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to honor a resident's expressed preference regarding her bedtime. The CNA took the resident from the dining room to her room after supper, changed her into a gown, and made her go to bed, despite the resident repeatedly stating she was not ready and wished to stay up longer to visit with friends. The CNA told the resident she was being put to bed because the CNA had other work to do. This incident was witnessed by the resident's roommate, who reported it to a registered nurse (RN). The RN confirmed the resident's account, found her sitting on the side of the bed, and offered to help her get up, but the resident declined at that time. The resident involved had a history of Parkinson's Disease and Depression and was assessed as having moderate cognitive deficits, with documented preferences indicating it was very important for her to choose her own bedtime. The facility's policy states that residents' rights, including the right to make choices about their daily lives, must be respected. The administrator, RN, and the resident herself all confirmed that her choice should have been honored, and the CNA involved had not returned to work since the incident.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure a resident's call light was within reach, as required by their policy. During an observation on 3/18/2024, Resident #4 was found lying in bed with the call light hanging down from the left side of the bed on the floor, making it inaccessible. On the following day, Resident #4 was observed sitting in a wheelchair and calling for help because she could not access her call light, which was hanging from the left bed rail positioned against the wall. The resident confirmed that she would use the call light to request help if it were accessible. Certified Nurse Aide (CNA) #1, who was assigned to Resident #4, acknowledged that the call light was unreachable and should not have been. The CNA explained that she had brought the resident to her room but was called away to attend to another task. The Director of Nursing (DON) confirmed that the call light should be accessible to the resident when she is in her room. Resident #4's medical history includes Cerebral Infarct, Type 2 Diabetes Mellitus, Epilepsy, and Paranoid Schizophrenia.
Failure to Honor Resident's Advance Directives
Penalty
Summary
The facility failed to honor a resident's preference for end-of-life Advance Directives. Resident #57 had initially signed an Advance Directive indicating a desire for life-sustaining treatment and a full code status. However, a hospice form signed by the resident's daughter changed the code status to Do-Not-Resuscitate (DNR) without the resident's knowledge or consent. The resident was not informed of this change, and it was not discussed with him when he was admitted to hospice services. The facility's Admission Liaison Nurse confirmed that there was no paperwork confirming the daughter as the Power of Attorney (POA) and acknowledged that the resident's end-of-life choice should have been according to his wishes. The Administrator also confirmed that the change in code status was not communicated through the proper channels. An interview with Resident #57 revealed that he was unaware of the change in his code status and expressed a clear desire for CPR if he stopped breathing. The resident's cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 11, showed moderate cognitive impairment. The facility's failure to honor the resident's advance directive and properly communicate the change in code status constitutes a deficiency in respecting the resident's rights and preferences for end-of-life care.
Failure to Notify Physician of Resident's Skin Concern
Penalty
Summary
The facility failed to notify a resident's physician of a skin concern for one of the sampled residents. Resident #216 was observed with an excessive thick layer of white buildup with patchy areas of flaking on the entire scalp, extending to the ear lobes and facial beard. The resident reported itching and revealed that the facility was not performing any treatment for the areas. Licensed Practical Nurse (LPN) #1 confirmed the skin concern but was unaware of any treatment or physician notification. The resident's physician orders did not include any treatment for the skin issue, and departmental notes did not document the concern. Registered Nurse (RN) #1 and LPN #2, who were responsible for skin audits, did not report any skin issues for Resident #216. The Director of Nursing (DON) confirmed that the skin concern should have been identified during weekly skin audits and that the physician should have been notified for treatment. The resident was admitted with medical diagnoses including Chronic Systolic Heart Failure and Type 2 Diabetes Mellitus.
Privacy Violation During Resident Care
Penalty
Summary
The facility failed to ensure privacy for a resident as evidenced by a staff member changing a resident's brief next to a window with no curtain or blind. An observation revealed that Resident #35's room had a window without any covering, exposing the resident to the outside view of a driveway with a trash dumpster and several parked cars. The resident expressed a desire for curtains on her window and was unsure why they were missing. A Certified Nurse Aide (CNA) confirmed that the window had been without a curtain or blind for an unspecified period and that they performed peri-care and brief changes while the resident was standing up due to her condition. Further observation showed the CNA changing the resident's brief and administering peri-care in front of the uncovered window. The Administrator confirmed the lack of window covering and acknowledged it as a privacy and dignity issue. Resident #35's medical records indicated she had Huntington's disease, slurred speech, and an anxiety disorder, with a moderately impaired cognitive status. The facility's policy on resident rights emphasized the importance of personal privacy, which was not upheld in this instance.
Failure to Complete Comprehensive Admission MDS Assessment
Penalty
Summary
The facility failed to complete a Comprehensive Admission Minimum Data Set (MDS) assessment within fourteen days for one of the sampled residents. Resident #216 was admitted on 2/21/2024, but the Admission MDS assessment with an Assessment Reference Date (ARD) of 2/28/2024 was not completed. The assessment was left open and unsigned by a Registered Nurse (RN). During an interview, the MDS Nurse confirmed that the assessment was overlooked and should have been completed within the required timeframe. The Director of Nursing (DON) was unaware of the incomplete assessment and confirmed that MDS assessments should be completed and submitted according to the Resident Assessment Instrument (RAI) guidelines.
Inaccurate MDS Assessments for Residents with Upper Body Contractures
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents with upper body contractures. Resident #34 was observed with a contracted left hand and fingers, and a gauze dressing in her palm due to a wound. Despite this, her MDS assessment indicated no impairment in the range of motion of upper extremities. The MDS Registered Nurse (RN) admitted to the error, stating she did not realize that contractures of the hand/fingers would be considered an upper extremity range of motion limitation. The Director of Nursing (DON) confirmed the inaccuracy in the MDS assessment for Resident #34. Similarly, Resident #46 was observed with paralysis and contractures in the left arm and fingers. However, his MDS assessment also indicated no impairment in the range of motion of upper extremities. The same MDS RN acknowledged the mistake, revealing that she did not reference the Resident Assessment Instrument (RAI) when completing the assessment. Both residents had physician orders for hand rolls to prevent further contractures, which were not accurately reflected in their MDS assessments.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, leading to unmet care needs. Resident #1, who required total assistance with ADLs due to severe cognitive impairment and spastic quadriplegia, was observed with poor oral hygiene, indicating that the care plan for oral care was not followed. Similarly, Resident #13, who required frequent oral care due to excessive secretion buildup, was found with dried secretions on his lips, and the care plan for PEG tube medication administration was not adhered to, as medications were not given individually as prescribed. Resident #26, who needed weekly nail care, was observed with excessively long nails, showing that the care plan for nail care was not followed. Resident #46, who had a contracture in the left hand, was observed without the prescribed hand roll device, indicating non-compliance with the care plan. Lastly, Resident #216, who was admitted with multiple medical diagnoses, did not have any care plans developed since admission, leaving the staff without guidance on how to care for the resident. Interviews with the Director of Nursing (DON) and Minimum Data Set (MDS) nurses confirmed that the care plans were not followed or developed as required. The DON acknowledged the deficiencies and the importance of care plans in guiding staff to meet the residents' needs. The lack of adherence to care plans and the absence of care plans for Resident #216 highlight significant gaps in the facility's care planning and implementation processes.
Failure to Follow Professional Standards for PEG Tube Medication Administration
Penalty
Summary
The facility failed to follow professional standards of practice for administering medications through a PEG tube for one resident. During an observation, an LPN crushed and administered multiple medications together without using flushes and gravity, contrary to the physician's order. The LPN was hesitant and questioned the technique but proceeded based on incorrect instructions. The Director of Nursing confirmed that the resident did not have a physician order to crush and administer the medications together and that the medications should be given individually with flushes between each to ensure compatibility and comfort. The resident involved had severe cognitive impairment and multiple medical diagnoses, including convulsions, gastrostomy status, dysphagia, and hypertension. The facility did not have a current policy on administering medications through a PEG tube, and the LPN misread the order, which specified that medications could be crushed and given together only if taken by mouth. The failure to follow the correct procedure was confirmed through staff interviews, record reviews, and facility policy reviews.
Deficiency in Resident Care
Penalty
Summary
The facility failed to ensure dependent residents received appropriate oral care, nail care, and shaving for four residents. Resident #1 was observed with a white, crusty substance on her lips, which was confirmed by her Resident Representative and staff members. Despite the facility's policy requiring frequent oral care, the resident's lips were not adequately cleaned, leading to dry, cracked skin and secretions. The Director of Nursing acknowledged the deficiency and the need for consistent oral care to prevent further issues. Resident #13 was also found with a large amount of thick, white dried substance on his lips during multiple observations. Staff interviews revealed that the resident's scopolamine patch, which helps reduce oral secretions, often came off without being reported, exacerbating the issue. The DON confirmed that the resident's oral care was not being performed as required, leading to the buildup of secretions on his lips. Resident #26 had long fingernails measuring three-eighths of an inch, which she stated had not been trimmed despite her desire for nail care. The DON confirmed that aides were responsible for trimming nails during bathing or as needed, and acknowledged the risk of skin injury due to the long nails. Resident #216 was observed with long facial hair, which he was unable to shave due to weakness in his arm. The DON confirmed that aides were responsible for shaving residents during bath days and upon request, but this had not been done for Resident #216.
Failure to Identify and Treat Resident's Skin Concern
Penalty
Summary
The facility failed to identify and treat a resident with a significant skin concern. Resident #216 was observed with an excessive thick layer of white buildup and patchy areas of flaking on the entire scalp, extending to the ear lobes and beard. The resident reported itching and stated that no treatment was being performed. Licensed Practical Nurse (LPN) #1 confirmed the skin concern but was unaware of any treatment orders. A review of the resident's physician orders and departmental notes revealed no treatment orders for the skin issue, and the skin concern was not documented in the resident's records. Registered Nurse (RN) #1 stated that the physician should have been contacted when the issue was first observed, but no staff had reported the skin issue to her. The Skin Inspection Reports also indicated that the resident had no identified skin concerns, which contradicted the observed condition. Further interviews revealed that LPN #2, responsible for completing the last two weeks of skin audits, did not find any skin concerns during her audits, admitting that she might have overlooked the issue. The Director of Nursing (DON) confirmed that the skin concern should have been identified during the weekly skin audits and that the physician should have been notified for treatment. The resident was admitted with medical diagnoses including chronic systolic heart failure, type 2 diabetes mellitus, vitamin D deficiency, and paroxysmal atrial fibrillation, but these conditions were not linked to the observed skin issue in the report.
Failure to Apply Hand Roll for Resident with Contracture
Penalty
Summary
The facility failed to apply a hand roll to a resident with a contracture as prescribed by the physician. The resident, who had a medical history including hemiplegia following cerebral infarction, type 2 diabetes mellitus, seizures, and depression, was observed on two separate occasions without the hand roll in place. The hand roll was ordered to be applied during waking hours to prevent further contractures. However, observations on 03/18/2024 and 03/19/2024 revealed that the resident did not have the hand roll applied, despite the order being documented in the Treatment Administration Record (TAR) and signed off on those dates. Interviews with the LPN and the Director of Nursing (DON) confirmed that the aides were responsible for applying the hand roll, and the nurses were responsible for ensuring it was in place. The LPN acknowledged that the hand roll was not applied, and the DON confirmed that not applying the hand roll could result in worsening contractures. The facility's policy on splint and brace application was reviewed, which emphasized the importance of using splints to prevent and/or correct contractures, but the policy was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 21.88%. During an observation, an LPN administered multiple medications through a PEG tube to a resident without following the physician's order to give each medication individually with a flush between each. The LPN crushed Vitamin C, Metoprolol Tartrate, Vitamin D3, Zestril, Hydrochlorothiazide, and Aspirin together and mixed them with liquid Keppra before administering them through the PEG tube. The LPN expressed hesitation about this method but proceeded based on incorrect instructions she received at the facility. Upon verification, it was found that there was no physician order to administer these medications together through the PEG tube. The Director of Nursing confirmed that the resident did not have a physician order to crush and administer the PEG medications together and that the medications should have been given individually to ensure compatibility. The LPN later admitted to misreading the order, which specified that medications could be crushed and given together if taken by mouth but must be given individually by PEG tube. The resident involved had severe cognitive impairment and multiple medical diagnoses, including convulsions, gastrostomy status, dysphagia, and hypertension. The facility also lacked a current policy on administering medications through the PEG tube, contributing to the medication error.
Unattended Medication Cart Keys
Penalty
Summary
The facility failed to ensure proper medication storage as evidenced by leaving keys for the medication cart, medication room, and controlled medication locked box unattended on the medication cart in the resident hallway. During an observation, an unattended medication cart was found with a set of keys on top of it. The LPN responsible for the cart was in a resident's room and not visible from the cart for approximately four minutes. Upon returning, the LPN acknowledged that leaving the keys unattended was unacceptable and posed a risk. The Director of Nursing confirmed that this lapse could have allowed unauthorized access to medications. Additionally, the facility did not have a policy for medication storage.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to decrease the likelihood of the spread of infection as evidenced by a nurse dropping a glove on the floor in a resident's room, retrieving it off the floor, putting it on, and continuing with medication pass and insulin administration. During an observation of medication pass, an LPN prepared a resident's medications, which included oral medications, a topical ointment, and a subcutaneous insulin injection. The LPN washed her hands and attempted to put on gloves, but one glove fell to the floor. She picked up the glove, placed it on her hand, and continued with the medication administration without changing the glove or washing her hands again. The LPN later acknowledged that she should have washed her hands and used new gloves to prevent the spread of infection, especially since one of the medications was an injection. An interview with the DON confirmed that proper infection control techniques were not used and that the facility failed to prevent the likelihood of the spread of infection. The facility's policy on infection prevention and control, dated 5/15/23, mandates that hand hygiene be performed according to established procedures and that PPE be used according to policy. The resident involved had multiple diagnoses, including Type 2 diabetes mellitus, Chronic Obstructive Pulmonary Disease, Epilepsy, Hypertension, and Schizophrenia, which could make them more vulnerable to infections.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage to two residents who were discharged from Medicare Part A services with service times remaining. The Administrator acknowledged the requirement for the Notice of Medicare Non-Coverage to be provided to the resident or the resident representative but admitted that it was not being done due to staff turnover and oversight. This deficiency was identified during a review of facility records and staff interviews. Resident #3 was admitted with a diagnosis of a displaced fracture of the base of the neck of the right femur and had a Medicare Part A skilled services episode start date of 10/3/23, with the last covered day being 11/15/23. Similarly, Resident #7 was admitted with diagnoses including unspecified combined systolic and diastolic congestive heart failure and acute kidney failure, with a Medicare Part A skilled services episode start date of 8/23/23, and the last covered day being 10/21/23. In both cases, the facility initiated the discharge from Medicare Part A services before benefit days were exhausted, and the Notice of Medicare Non-Coverage form was not provided to the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shearer-richardson Memorial Nursing Home | 15 mi | ★★★★★ | 5 | 0 |
| Baptist Nursing Home-calhoun, Inc | 19.4 mi | ★★★★★ | 1 | 0 |
| Bruce Community Living Center | 23 mi | ★★★★★ | 6 | 0 |
| Pontotoc Health & Rehab Center | 23.7 mi | ★★★★★ | 3 | 0 |
| Pontotoc Nursing Home | 24.2 mi | ★★★★★ | 0 | 0 |
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