Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Caraday Of Houston during CMS and state inspections, most recent first.
Failure to Supervise a High-Fall-Risk Resident: A resident with stroke-related weakness, cognitive deficits, and a history of multiple falls was left without adequate supervision and had an unwitnessed fall from her wheelchair. She was found on the floor in her room, could not explain the event, and later required hospitalization and cervical spine surgery for a C6-C7 fracture. Her care plan did not reflect the post-surgical precautions, transfer assistance, or supervision needs documented after the injury.
The facility failed to designate an RN to serve as DON on a full-time basis and failed to provide RN coverage for two reviewed days. PBJ data showed no RN hours, and RN coverage timesheets confirmed no RN worked on those dates. The Administrator stated the facility had been without a DON for about 30 days and had staffing shortages affecting RN coverage, despite a policy requiring RN services for at least 8 consecutive hours per day, 7 days per week.
A resident with repeated falls, cognitive impairment, and new post-surgical needs after a neck fracture did not have a comprehensive, updated care plan. The existing plan still contained an older fall intervention and did not include new directions for the cervical collar, one-to-one supervision, or other post-op needs. Staff interviews showed CNAs were relying on verbal shift report rather than written care plan interventions, and observations found the resident at times without the collar and without fall mats in place.
Failure to Change Gloves and Perform Hand Hygiene During Peri-Care: Two CNAs provided incontinent care to a resident with quadriplegia, aphasia, urinary issues, G-tube, colostomy, and impaired cognition, but after cleaning the resident’s peri-area they did not remove gloves, perform hand hygiene, or don clean gloves before handling clean briefs, bedding, and the resident’s face. Both CNAs acknowledged the lapse, and the ADON stated gloves should be removed and hand hygiene performed after the dirty portion of peri-care.
A resident with COPD, prior CVA with hemiplegia/hemiparesis, cognitive communication deficit, and dysphagia developed a significant change with garbled, slurred speech and altered responsiveness. An RN texted the MD that the resident was not herself, but did not answer when the MD asked if it looked like a stroke. The change was not escalated to the NP until many hours later, and the resident was not sent to the hospital until late the next morning; hospital records showed altered mental status and acute CVA.
A resident with prior CVA-related deficits, dysphagia, and communication problems developed a sudden change in speech that was noticed by an LPN. The LPN texted the MD, but did not follow up after the MD asked whether the resident might have had a stroke. An overnight nurse monitored the resident but did not promptly escalate the change, and the next nurse did not receive a clear report of the concern until later. The resident was eventually assessed, found to have aphasic speech, and sent to the ER, where she was diagnosed with altered mental status and acute CVA.
A resident who required staff assistance for bathing was unable to take showers according to personal preference due to a prolonged lack of hot water, as confirmed by multiple residents, staff, and maintenance records. The facility's failure to maintain adequate water temperature prevented residents from exercising their rights to self-determination and personal hygiene.
Two residents with cognitive and behavioral impairments were involved in a physical altercation in the dining room, resulting in one resident sustaining a facial injury. The incident was witnessed by staff and another resident, and the aggressor admitted to the act. Despite care plans identifying risks and interventions for aggression, staff did not prevent the altercation, leading to a deficiency in protecting residents from abuse and neglect.
A medication aide left a cup containing multiple pills, labeled for a resident, unattended on a medication cart while the resident was unavailable. Staff interviews confirmed that this practice violates facility policy, which requires medications to be prepared and administered to only one resident at a time and not left unattended. The incident demonstrated noncompliance with regulations for secure storage and proper labeling of medications.
Two residents' rooms were found to have ongoing gnat infestations, with gnats observed on walls, personal items, and a urinal placed on the floor. Staff interviews indicated that pest control services and in-house treatments were performed, but the issue persisted, possibly due to urine spills and overflowing trash. The facility's pest control contract did not cover flying insects like gnats, and repeated treatments were documented without resolution.
Failure to Supervise a High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards and failed to provide adequate supervision for a resident with a documented history of falls and fall risk. Resident #46 had diagnoses including cerebral infarction, muscle wasting and atrophy, muscle weakness, and cognitive communication deficit. Her MDS reflected poor decision-making and need for supervision, and her care plan identified multiple prior falls and fall-prevention interventions, including reminders to lock her wheelchair, keeping the bed low and locked, keeping the call light and personal items within reach, maintaining clear pathways, and encouraging her to call for assistance. The care plan also included an intervention not to leave her in her wheelchair next to the bed. On 05/07/26, Resident #46 had an unwitnessed fall in her room in front of her wheelchair. Staff documentation stated she was found on the floor and could not explain what happened. One note stated she was wheelchair dependent and to continue fall precautions due to mobility limitations and hemiparesis. A CNA witness statement indicated the resident agreed she attempted to transfer without assistance and fell. Another witness statement described the resident as unstable and sliding down from her wheelchair. The facility investigation also noted the witness statement did not include the assigned charge nurse or CNA. The fall resulted in a cervical spine fracture at C6-C7 and hospitalization from 05/07/26 to 05/18/26, followed by spine surgery on 05/09/26. The hospital discharge information stated the resident had presented after a fall from her wheelchair and recommended one-to-one supervision. An OT evaluation after hospitalization documented impaired ADLs, impaired endurance, and impaired functional mobility. Upon return to the facility, the resident’s care plan had not been revised to include the post-surgical cervical spine precautions, positioning requirements, transfer assistance, supervision needs, or monitoring needs that were identified in the record.
Failure to Maintain Required RN and DON Coverage
Penalty
Summary
The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis and failed to provide RN coverage for 05/18/2026 and 05/25/2026 to meet the requirement for an RN working a full 8 hours a day. Record review of the facility’s PBJ data for fiscal year 1 2026 showed the result as “Not Triggered” for no RN hours, and review of RN coverage timesheets showed no RN worked on those two dates. During an interview on 05/28/2026 at 3:44 p.m., the Administrator stated the facility had been without a DON for approximately 30 days. She stated that when a DON was not present, the facility typically assigned other RNs to cover DON responsibilities, but staffing shortages had recently affected coverage. She also stated the DON position had been posted on Indeed and that a new DON was anticipated to start at the beginning of the next month. The facility policy for Nursing Services-Registered Nurse, revised on 05/30/2025, stated the facility would utilize the services of an RN for at least 8 consecutive hours per day, 7 days per week, and would designate an RN to serve as the DON on a full-time basis.
Care Plan Not Updated for Falls and Post-Surgical Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of repeated falls and new post-surgical needs. The resident was a female with a history of cerebral infarction, muscle wasting and weakness, and cognitive communication deficit. Her MDS documented poor decision-making and need for supervision, and her care plan identified her as high risk for falls with a history of multiple falls, including falls on 2/1/26, 2/15/26, 2/23/26, 3/10/26, and 5/7/26. The care plan contained an older intervention stating not to leave her in a wheelchair next to the bed, but it was not updated after the later fall and did not include new interventions related to the cervical injury or post-operative care. After the resident’s fall from her wheelchair, hospital discharge documentation stated she had sustained a neck fracture and required two major surgeries. The discharge recommendations included one-to-one supervision, and the postoperative plan required her to wear a Miami J collar at all times and avoid bending, lifting, and twisting for 2 to 3 months. An OT evaluation noted impaired ADLs, impaired endurance, and impaired functional mobility. When the resident returned to the facility, the re-admission order stated that she must have the cervical collar on at all times until her surgeon follow-up, but the care plan still did not reflect updated interventions for the collar or the resident’s changed condition. Observations after re-admission showed the resident lying in bed with the hard cervical collar on at one time, but later she was observed in bed without the collar, with the collar placed on the bedside table out of reach. The room did not have fall mats on either side of the bed. Interviews with staff showed that CNAs were being told the resident’s care needs verbally by the charge nurse rather than through written care plan interventions, and one CNA stated she did not know how to review care plan interventions. The administrator stated the nursing staff should review the care plan daily and review changes, while the ADON stated the resident’s ADL care had changed after return and that she requested review for a significant change assessment because the resident had not met the 14-day timeframe.
Failure to Change Gloves and Perform Hand Hygiene During Peri-Care
Penalty
Summary
The facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one resident reviewed for infection control. During observed incontinent care, CNA X and CNA Y both wore gloves while providing peri-care to a resident who required staff assistance with toileting, personal hygiene, bed mobility, and transfers. The resident had diagnoses including quadriplegia, aphasia, urinary tract infection, neuromuscular bladder dysfunction, gastrostomy status, colostomy status, dysphagia, and a brain disorder, and the quarterly MDS indicated short- and long-term memory problems and moderately impaired cognitive skills for daily decision making. During the observation, the CNAs gathered supplies, washed their hands, and put on gowns and gloves before beginning care. They unfastened the resident’s brief, rolled it down, turned the resident side to side, removed the soiled brief, and cleansed the lower abdomen, groin, penis, urethral meatus, scrotum, buttocks, and anal area with disposable wipes. After the cleaning portion, CNA X positioned a clean brief under the resident and both CNAs fastened it. CNA X and CNA Y then touched the resident’s gown, bedding, and covers, and CNA Y touched the resident’s head and face and wiped his mouth with a moistened washcloth. CNA X and CNA Y did not remove used gloves, perform hand hygiene, or put on clean gloves after cleaning the resident and before handling the clean brief, bedding, and the resident’s face and head. In interview, both CNAs stated they knew they should have changed gloves and performed hand hygiene after the dirty part of peri-care and before touching clean items. CNA Y stated she should not have touched the resident’s face with gloves used for incontinent care. The ADON stated hands should be washed and gloves changed to prevent infection, and that after the cleaning portion of peri-care, gloves are to be removed, hand hygiene performed, and clean gloves put on because the gloves would be dirty and should no longer touch linen, clean briefs, or the resident’s skin.
Failure to promptly notify physician and representative of significant change in condition
Penalty
Summary
The facility failed to immediately consult the resident’s physician and notify the resident representative when the resident had a significant change in condition. Resident #1 was a female with diagnoses including COPD, hemiplegia and hemiparesis following cerebral infarction, cognitive communication deficit, and dysphagia. Her MDS showed intact cognition with unclear speech and difficulty making herself understood. Her care plan identified a communication problem and directed staff to allow extra time, repeat as needed, ask for clarification, and monitor for confounding problems such as decline in cognitive status and oral motor function. On 05/01/26 in the evening, Nurse A documented that the resident was in bed watching TV but was not as vocal as normal, then began singing and speaking garbled English. Nurse A texted the physician that the resident was not herself and denied pain, and the physician replied asking whether it looked like a stroke. Nurse A did not respond to that question and later stated he did not complete a full consultation or a full-body assessment before the end of his shift. He reported the resident’s condition to the oncoming nurse, Nurse B, but did not complete the physician follow-up. The physician later stated she did not hear back from Nurse A and would have needed more information to determine what was happening. Nurse B stated he monitored the resident overnight and observed that her speech remained slurred and difficult to understand, including around 5:00 a.m. to 5:30 a.m. when he felt it looked like seizure activity. He said he reported this to Nurse C at shift change and asked him to assess the resident and call the doctor, but Nurse C stated he did not receive that report and only learned later that the resident may have had a stroke. The change in condition was not reported to the NP until about 10:48 a.m., approximately 12 hours and 36 minutes after the initial change was recognized, and the resident was not transported to the hospital until about 11:42 a.m. Hospital records showed altered mental status and acute CVA.
Delayed Response to Change in Speech and Possible Stroke
Penalty
Summary
The facility failed to ensure timely treatment and care for a resident who had a change in speech and later was diagnosed with an acute CVA. The resident had diagnoses including COPD, hemiplegia and hemiparesis following cerebral infarction, cognitive communication deficit, and dysphagia. Her MDS showed intact cognition with unclear, slurred, or mumbled speech and difficulty making herself understood. Her care plan identified a communication problem and included interventions such as allowing extra time to respond, repeating as needed, requesting clarification, and using simple, brief cues. On the evening of the event, Nurse A noticed the resident was not as vocal as normal and then began speaking garbled English. Nurse A texted the physician, who asked whether the resident appeared to have had a stroke, but Nurse A did not follow up with the physician after that exchange. Nurse A later documented that the resident was in bed watching TV, was not as vocal as normal, and was singing and speaking garbled English, and that the physician had been notified and asked if it appeared the resident had a stroke. Nurse A also told the oncoming nurse that the resident was not vocal and that the physician wanted to know if it appeared she had had a stroke. Nurse B was told the resident's speech was not clear and that it took her longer than usual to respond, and he monitored her overnight. He reported that around 5:00 a.m. to 5:30 a.m. the resident was awake and still had slurred speech, but he did not document a full assessment that could be located. He said he told Nurse C at shift change that the resident's speech was slurred and that it looked like she had seizure activity, but Nurse C stated he was not told that anything was wrong with the resident's speech or that seizure activity was suspected. Nurse C later assessed the resident after receiving a phone call and noted aphasic speech, easy arousal, no facial drooping, normal movement of the left arm and leg, and no respiratory distress, and the NP ordered transfer to the ER. The resident was transferred by EMS and the hospital diagnosed altered mental status and acute CVA.
Failure to Ensure Resident Choice Due to Lack of Hot Water for Showers
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not ensuring the availability of hot water, which prevented residents from taking showers according to their preferences. One resident, who had normal cognitive functioning and required staff assistance for bathing due to impaired mobility and contractures, was unable to exercise his right to choose when and how to bathe because the water temperature was consistently too cold. Documentation showed that the resident repeatedly expressed dissatisfaction with the lack of hot water, refusing to shower until the water temperature met his preference. Multiple records and interviews confirmed that the hot water issue persisted for an extended period, with several residents reporting that they could not bathe or shower for weeks due to cold water. Staff, including an RN, acknowledged that the facility frequently lost hot water in the residential areas, particularly in the showers, and that residents' complaints were communicated to both administration and the ombudsman. Maintenance staff identified a failed pump in the boiler room as the cause, which affected water temperatures throughout the building, especially when the kitchen and laundry were in use. The facility's own policies required maintaining a safe, clean, and homelike environment, including reasonable accommodation of resident preferences and support for daily living activities. Despite these policies, the lack of hot water directly impacted residents' ability to maintain personal hygiene and exercise their rights regarding daily routines, as confirmed by resident and ombudsman interviews and facility documentation.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect when a resident-to-resident physical altercation occurred in the dining room. One resident, who had a history of cognitive impairment, anxiety, bipolar disorder, and communication deficits, was struck in the face by another resident, resulting in bleeding from the left eye. The incident was witnessed by a dietary aide and another resident, and it was reported that the aggressor admitted to hitting the other resident after being called a name. The injured resident refused medical assessment and treatment from both nursing staff and EMS, but an X-ray later confirmed there was no facial bone fracture or dislocation. The aggressor had a documented history of moderate cognitive impairment, cerebrovascular disease, hypertension, and behavioral issues, including poor impulse control and a tendency toward verbal altercations. His care plan identified a risk for physical aggression and outlined interventions such as monitoring for triggers, providing cues to alleviate anxiety, and involving psychiatric and psychological services. Despite these interventions, the resident engaged in a physical altercation, which was not prevented by staff. Interviews with staff and residents indicated that this was the first known physical altercation involving the aggressor, although verbal altercations had occurred previously. The facility's policy required protection of residents from abuse and neglect by anyone, including other residents. However, the failure to prevent the altercation and ensure the safety of both residents constituted a deficiency in upholding residents' rights to be free from abuse and neglect.
Medications Left Unattended on Medication Cart
Penalty
Summary
A medication aide was observed leaving a medication cup containing at least seven pills, labeled for a specific resident, unattended on a medication cart. The aide explained that the resident was taking a shower and intended to return to administer the medications later. Multiple staff interviews confirmed that facility protocol prohibits leaving open medications unattended on the cart, and that medications should be prepared for only one resident at a time and administered immediately. Staff also stated that pre-popping medications is not allowed, as it can lead to confusion about which medications are in the cup and may prevent proper verification of medication rights, such as checking vital signs before administration. A review of the facility's policy on medication preparation and administration confirmed that staff are required to observe the six rights of medication administration and to prepare medications for only one resident at a time. The failure to follow these procedures was directly observed and acknowledged by staff, with the medication cup left on the cart while the resident was unavailable. This incident demonstrated noncompliance with state and federal requirements for the secure storage and proper labeling of drugs and biologicals, as well as facility policy.
Failure to Maintain Effective Pest Control Program Resulting in Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in resident rooms. Observations revealed gnats on the walls, pictures, lighting, and on a urinal placed on the floor in a resident's room. Interviews with the resident and housekeeping staff confirmed the ongoing issue, with staff noting that the room always had gnats and suggesting possible causes such as overflowing trash or food left out. The resident reported that a substance had been placed by maintenance to catch the gnats, but it was ineffective. Additional interviews with nursing and maintenance staff indicated that pest control had recently sprayed the facility and the affected room, but gnats persisted. Maintenance staff tracked treatments in a log and reported treating the room weekly, but acknowledged that gnats were always present. Record review showed that the facility's pest control contract did not cover flying insects such as gnats, and that additional service for these pests would incur extra fees. Maintenance logs documented repeated treatments for gnats in the affected rooms over several days. Staff interviews suggested that the source of the gnats may be related to a resident's use of a urinal and urine spills on the floor, as well as the resident's desire for independence. Despite regular pest control visits and additional in-house treatments, the facility was unable to eliminate the gnats, resulting in unsanitary living conditions for the residents involved.
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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) |
|---|---|---|---|---|
| Ashford Gardens | 0.8 mi | ★★★★★ | 24 | 0 |
| West Janisch Health Care Center | 1.6 mi | ★★★★★ | 19 | 4 |
| Highland Park Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Houston Heights Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 2 | 0 |
| Avir At Veterans Memorial | 4.7 mi | ★★★★★ | 22 | 3 |
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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 August 2026) and official state health department websites.