Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Avir At Courtyard during CMS and state inspections, most recent first.
Inaccurate PASRR Level I Screenings for two residents with documented mental health diagnoses were identified. One resident had schizoaffective disorder, PTSD, adjustment disorder, and depression, while the other had paranoid schizophrenia, anxiety disorder, and delusional disorders; both screenings incorrectly indicated no evidence of mental illness. Records also showed psychotropic meds, active psych diagnoses, and care plan interventions related to mood and behavioral health.
Inaccurate MDS Did Not Code Dialysis: A resident with ESRD and ordered renal dialysis had both the admission MDS and quarterly MDS coded as “none of the above” for dialysis in the Special Treatments, Procedures section. The resident’s record also showed dialysis orders and a care plan addressing dialysis-related needs, while the DON and Regional Nurse Consultant stated the MDS should accurately reflect the resident’s conditions and treatments.
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as flies and roaches in the kitchen and conference room. Despite having a pest control contract, staff and residents reported ongoing issues with cockroaches in various areas, including resident rooms. The facility's pest control policy was not effectively implemented, leading to these deficiencies.
A resident with multiple medical conditions was improperly discharged from a facility without necessary documentation and communication to ensure a safe transition of care. The resident, who had moderate cognitive impairments, was sent to the ER due to noncompliance with medication and wound care, but the facility failed to provide a discharge summary or inform the hospital that the resident was not to return. Interviews with staff revealed that the discharge process did not follow the facility's policy, lacking sufficient documentation and communication.
A facility failed to readmit a resident after hospitalization, lacking proper documentation and communication with the resident's responsible party and physician. The resident, with multiple medical conditions, was sent to the hospital for noncompliance with medication and wound care. Staff interviews revealed inadequate discharge documentation and communication, contrary to the facility's policy on safe and orderly transfers.
Two residents in the facility were inaccurately assessed in their annual comprehensive MDS assessments. One resident, with multiple health conditions, was noted to have no oral issues despite having dentures. Another resident, also with significant health issues, was incorrectly assessed as having no oral problems, although she had ill-fitting dentures causing discomfort. The MDS Coordinator confirmed the inaccuracies, and the facility's policy did not address MDS accuracy.
A resident with blindness and other health conditions was not provided with necessary nail care assistance, leading to long, dirty fingernails and self-injuries. Despite requests for help, the facility failed to adhere to its policy on ADL care, resulting in unmet needs for the resident.
The facility failed to properly store and label medications, with observations revealing expired and improperly stored drugs in medication carts. At Station 1, a nurse's cart contained a controlled medication for a discharged resident, and a medication aide cart had multiple medications for another discharged resident. At Station 2, a nurse's cart contained expired medications. Staff interviews revealed a lack of adherence to protocols for handling medications of discharged residents and ensuring medications are dated and discarded appropriately.
A resident with intact cognition reported that her dentures did not fit and caused pain, yet the facility failed to address her concerns. Observations confirmed she had no teeth, and the MDS assessment inaccurately indicated no oral problems. The facility administrator acknowledged the importance of accurate assessments to prevent service delays.
The facility failed to adhere to food service safety standards, with observations revealing unclean deep fryer grease, stagnant water in the dishwashing area, and pest issues. The Dietary Manager acknowledged the overdue grease change and the need for cleaning, while the Facility's Administrator noted multiple flying insects, indicating a potential pest problem.
The facility failed to maintain an effective infection control program, as evidenced by a housekeeper wearing gloves while pushing a dirty trash can, risking cross-contamination, and a CNA not following proper hand hygiene during incontinent care for a resident with cognitive impairment. These actions violated the facility's infection control policies, potentially placing residents at risk.
A facility failed to maintain a resident's electric bed remote in safe operating condition, leaving the bed in a high position and posing a risk of injury. Staff interviews revealed a lack of timely reporting to maintenance, and the facility's preventive maintenance policy was not followed, potentially endangering the resident's safety.
Inaccurate PASRR Level I Screenings for Residents With Mental Illness
Penalty
Summary
The facility failed to ensure that two residents with documented mental health diagnoses had accurate PASRR Level I screenings. For Resident #1, the record showed diagnoses including schizoaffective disorder, bipolar type, PTSD, adjustment disorder with mixed anxiety and depressed mood, and depression. Despite these diagnoses, the PASRR Level I Screening completed at the hospital indicated that there was no evidence or indicator of mental illness. The resident’s record also included psychotropic medications such as divalproex sodium, Effexor XR, and quetiapine, along with care plan entries related to depression and schizoaffective disorder. Resident #56 also had a record of mental illness diagnoses, including paranoid schizophrenia, anxiety disorder, and delusional disorders. Her quarterly MDS listed active diagnoses of depression, psychotic disorder, and schizophrenia, and her PASRR Level I Screening completed at the facility indicated that there was no evidence or indicator of mental illness. Her care plan included a focus area for mood problems related to bipolar disorder/schizophrenia and an intervention for behavioral health consults as needed. During interviews, the Regional Reimbursement Coordinator stated that it was the MDS coordinator’s responsibility to have a completed PASRR Level I upon admission and that Level I screenings are usually completed on admission but no later than 72 hours after admission. The Former MDS Coordinator stated she was responsible for submitting PASRR Level I screenings within 48 to 72 hours after admission and that a correct Level I was important because residents could miss out on PASRR services if it was not completed correctly. The facility policy stated that PASRR is intended to ensure individuals with mental illness or intellectual disabilities receive appropriate care and services.
Inaccurate MDS Did Not Code Dialysis
Penalty
Summary
Resident #7’s assessment was not accurate because the MDS did not code dialysis in the Special Treatments, Procedures section, even though the resident had renal dialysis ordered and documented. Record review showed the resident was admitted with diagnoses including vascular dementia, cerebral infarction, renal dialysis, dysphagia, end stage renal disease, and diabetes. The most recent physician’s order listed renal dialysis on Tuesday, Thursday, and Saturday, and the care plan identified dialysis needs related to renal failure with interventions for dialysis site care and monitoring for changes. The admission MDS and the quarterly MDS both coded “none of the above” for dialysis. During interview, the DON stated the MDS should be accurate and reflect all resident conditions and treatments, and the Regional Nurse Consultant stated the MDS should accurately describe the resident and that the interdisciplinary team contributes to the assessment, with the MDS nurse finalizing it. The facility policy on Resident Assessments stated that comprehensive assessments are used to develop, review, and revise the comprehensive care plan.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in multiple areas, including the kitchen and conference room. Observations revealed flies and other flying insects in the conference room, as well as live roaches under the kitchen sink, on the wall above the sink, and near the dishwasher. Interviews with the facility Administrator and staff indicated that the facility had a pest control contract, but pests were still prevalent. The Dietary Manager mentioned that the pest control company had sprayed the facility a few weeks prior, but issues persisted. Interviews with residents and staff further highlighted the pest problem, with reports of cockroaches in resident rooms and around the facility. A resident mentioned seeing cockroaches in her room, and a housekeeper confirmed sightings of roaches in resident rooms and other areas. The pest control staff suggested keeping floors dry to prevent rodent issues, while other staff members noted the presence of cockroaches but had not seen them in food. The facility's pest control policy outlined measures for maintaining an insect and vermin-free environment, but these measures were not effectively implemented, leading to the observed deficiencies.
Improper Discharge and Inadequate Documentation for Resident
Penalty
Summary
The facility failed to properly discharge a resident, identified as Resident #61, without providing all necessary information and documentation to ensure a safe and effective transition of care. The resident, a male with multiple medical conditions including osteomyelitis, essential hypertension, mixed hyperlipidemia, muscle wasting, and a stage 4 pressure ulcer, was discharged without a discharge summary or adequate documentation in his medical record. The resident had a BIMS score indicating moderate cognitive impairments and required assistance with mobility and personal care. The discharge process was inadequately handled, as evidenced by the lack of communication with the resident's responsible party, the ombudsman, or the home health agency. The facility's records did not include a discharge summary or any documentation indicating the resident's transition plan. The resident was transported to the emergency room due to noncompliance with medication and wound care, and there was no documentation that the hospital was informed that the resident was not to return to the facility. Interviews with facility staff, including the Administrator, ADON, and MDS Coordinator, revealed that the discharge process did not follow the facility's policy. The staff acknowledged that there was insufficient documentation and communication regarding the resident's discharge, which could have impacted the resident's care and safety. The facility's policy required informing the resident and their family about the discharge, ensuring safe transportation, and providing necessary information to the receiving facility, which was not adhered to in this case.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to establish and follow a written policy on permitting residents to return after hospitalization, specifically affecting one resident who was not readmitted after being sent to the hospital. The resident, a male with multiple medical conditions including osteomyelitis, hypertension, and a stage 4 pressure ulcer, was transported to the hospital due to noncompliance with medication and wound care. The facility did not provide evidence of notifying the resident's responsible party or physician about the discharge to the hospital. Interviews with facility staff revealed a lack of proper documentation and communication regarding the resident's discharge. The administrator acknowledged that there should have been more documentation about the discharge and that it was not communicated to the hospital that the resident was not to return. The ADON and MDS Coordinator also highlighted the importance of notifying the family and physician, documenting the discharge, and ensuring the resident's safety, which were not adequately addressed in this case. The facility's policy on transfer, discharge, and return emphasizes the need for preparation and orientation of the resident to ensure a safe and orderly transfer. However, the policy was not followed, as the resident was not informed about the discharge, and there was no documentation of the discharge summary or communication with the hospital. This oversight could potentially place residents at risk of being denied readmission and result in violations of resident rights.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to conduct accurate and comprehensive assessments of residents' functional capacities, specifically for two residents out of the sixteen reviewed. Resident #46, a male with multiple diagnoses including Type 2 diabetes and pulmonary emphysema, was inaccurately assessed in his annual comprehensive MDS assessment. The assessment indicated no problems with his oral cavity, despite the resident having dentures, which he confirmed during an interview. Similarly, Resident #113, a female with conditions such as hypertension and heart failure, was also inaccurately assessed. Her MDS assessment incorrectly noted no oral cavity issues, although she had dentures that did not fit and caused her discomfort, as observed and confirmed in an interview. The MDS Coordinator acknowledged the inaccuracies in the assessments of both residents, noting that Resident #113's dentures were not worn due to discomfort, and Resident #46 had previously mentioned his dentures. The facility's policy on MDS assessment accuracy was requested but did not address the accuracy of assessments. The facility administrator expressed an expectation for all MDS assessments to accurately reflect residents' conditions, acknowledging that inaccuracies could delay necessary services.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care, treatment, and services to maintain or improve the ability of a resident to carry out activities of daily living (ADLs). Specifically, the facility did not assist Resident #23 with nail care, despite the resident's inability to perform this task independently due to blindness and other health conditions. Observations revealed that the resident had long, dirty fingernails, which he reported had caused self-injuries, particularly around his eyes. The resident expressed that he had requested assistance with trimming his nails but was repeatedly told that someone would return to help, which did not occur. The resident's medical history includes cerebrovascular diseases, blindness, essential hypertension, osteoarthritis of the knee, and depression. He was cognitively intact with a BIMs score of 14 out of 15, indicating he was aware of his needs and surroundings. The care plan for the resident highlighted the need for supervision and limited assistance with ADLs to maintain dignity and hygiene. However, the facility's failure to adhere to its policy on ADL care, specifically regarding nail care, resulted in the resident's needs not being met in a timely manner, as evidenced by the observations and interviews conducted during the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional principles, as observed in medication carts at two stations. At Station 1, a nurse's medication cart contained a blister packet of Lorazepam 0.5mg for a discharged resident, which should have been removed to prevent potential administration to another resident or drug diversion. Additionally, a medication aide cart at the same station contained six blister packets of medications for a resident who had been discharged, along with an open and undated fluticasone propionate nasal spray. The medication aide was unaware of the protocol for handling medications of discharged residents. At Station 2, a nurse's cart contained expired Imodium A-D Loperamide hydrochloride tablets and an opened latanoprost ophthalmic solution that was past its discard date. The nurse acknowledged that expired medications should not be administered as they would not be effective. The Assistant Director of Nursing (ADON) confirmed that medications should be dated upon opening and discarded by their expiration date. The facility's undated medication storage policy indicated that no discontinued, outdated, or deteriorated medications should be available for use, but this was not adhered to in practice.
Failure to Provide Appropriate Dental Care
Penalty
Summary
The facility failed to provide appropriate dental care for a resident, identified as Resident #113, who was reviewed for dental services. Despite having dentures, the resident reported that they did not fit properly and caused pain when worn. The resident indicated that no one at the facility had inquired about her dentures, and she had been managing to eat without them. Observations confirmed that the resident had no teeth in her oral cavity, and interviews with the resident and staff corroborated the issue with the dentures. The resident's medical history included conditions such as hypertension, heart failure, and chronic obstructive pulmonary disease, among others. Her cognitive assessment showed intact cognition with a BIMS score of 13 out of 15. However, the MDS assessment inaccurately reflected her oral status as having no problems, which was contradicted by the resident's own account and the observations made. The facility administrator acknowledged the expectation for accurate MDS assessments, noting that inaccuracies could delay necessary services.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to maintain food service safety standards, as evidenced by observations of the kitchen and dishwashing areas. During a kitchen inspection, it was noted that the deep fryer contained dark grease with brownish substances on top, indicating that the grease had not been changed as per the usual schedule. The Dietary Manager acknowledged that the grease was overdue for a change and committed to addressing the issue. Additionally, there was a buildup of grease around the oven range, which also required cleaning. In the dishwashing area, stagnant water was observed between the rinse sink and the dishwasher, and there were black substances on the walls surrounding the area. The Dietary Aide explained that the water was a result of spraying dishes and the dishwashing machine. The Dietary Manager admitted it was her first time noticing the stagnant water and planned to have the Maintenance Director investigate. Furthermore, the Facility's Administrator observed multiple flying insects under the sink and around the dishwashing machine, indicating a potential pest issue. The facility's policy outlined specific cleaning procedures, including the use of sanitizing agents and regular cleaning schedules, which were not adhered to, leading to these deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff members. In the first incident, a housekeeper was observed pushing a dirty trash can in the hallway while wearing gloves, which she acknowledged was against infection control protocols due to the risk of cross-contamination. Despite being in-serviced on proper PPE use and infection control, the housekeeper did not adhere to the guidelines, and this was confirmed by both the Environmental Manager and the Administrator. In the second incident, a CNA providing incontinent care to a resident with moderate cognitive impairment failed to follow proper hand hygiene protocols. The CNA used the same gloved hands to clean the resident and retrieve wipes from a multi-wipe packet multiple times without washing or sanitizing her hands before changing gloves. This practice was identified as an infection control issue by both the Interim DON and the ADON, who noted the risk of cross-contamination and the potential transfer of germs from the gloves to the wipe packet. The resident involved in the second incident was an elderly female with a history of atrial fibrillation, hypertension, and dementia, requiring extensive assistance with activities of daily living. The facility's policies on housekeeping, PPE, and handwashing emphasize the importance of preventing the spread of infection, yet these protocols were not followed in the observed incidents, leading to potential risks for the residents.
Failure to Maintain Safe Operating Condition of Bed Remote
Penalty
Summary
The facility failed to ensure that all mechanical, electrical, and patient care equipment was in safe operating condition, specifically for one resident who was reviewed for safe operating patient care equipment. The deficiency involved the malfunctioning of an electric bed remote for a resident with moderate impaired cognition and multiple health conditions, including atrial fibrillation, hypertension, and dementia. The resident required extensive assistance with activities of daily living. Observations revealed that the resident's bed was in a high position due to the remote control not functioning properly, which posed a risk of injury if the resident were to fall out of bed. Interviews with staff, including a registered nurse, certified nursing assistants, and the assistant director of nursing, indicated that the malfunctioning remote had not been reported to maintenance in a timely manner. The staff were either unsure of the reporting process or unaware of the issue until it was brought to their attention. The maintenance assistant confirmed that there was no repair request for the bed remote, and the maintenance director was unavailable due to illness. The facility's policy on preventive maintenance was not followed, as the malfunctioning equipment was not addressed promptly, potentially endangering the resident's safety.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Golfcrest | 0.5 mi | ★★★★★ | 1 | 1 |
| Afton Oaks Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 12 | 7 |
| Harmony Care At Golfcrest | 2 mi | ★★★★★ | 7 | 0 |
| Paradigm At Faith Memorial | 5.4 mi | ★★★★★ | 18 | 0 |
| Richard A. Anderson (state Of Texas Veterans Land | 5.7 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.