Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
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 Chelsea Gardens during CMS and state inspections, most recent first.
Odor in Resident Rooms and Common Areas: Surveyors observed a musty, moldlike odor in the hallway to the conference room and in the conference room, and two residents were found in rooms with carpet odors. One resident said the carpet smelled like urine and feces, while the other resident's family requested a room change because the carpet did not smell good. Staff interviews confirmed that housekeeping was responsible for carpet cleaning and odor control, and the ADM acknowledged an odor in a room.
A resident with ESRD, bilateral amputations, severe cognitive impairment, dysphagia, and a documented history of choking was not provided a comprehensive care plan that clearly addressed his dysphagia, prior choking episodes, and need for continuous supervision and assistance with eating. Although progress notes, diet orders, and family input showed he required a mechanical soft diet and close monitoring during meals, the care plan lacked a specific dysphagia focus and did not clearly communicate his choking risk to staff. On the night of the event, after the dietary manager prepared a requested sandwich and informed staff that the resident would need assistance with eating, the tray was delivered and the resident was left alone in his room; video later showed no staff entering for an extended period. When a CNA eventually entered to feed him, the resident was found unresponsive with part of a sandwich in his hand and food leaking from his mouth, and EMS documented his airway was completely obstructed by emesis containing food material.
A resident with ESRD, dysphagia, severe cognitive impairment, and a documented need for assistance and monitoring during meals was given a turkey sandwich and left alone in his room after returning from dialysis. Despite prior choking episodes, NP instructions to monitor meals for safety, and the family’s repeated requests that staff supervise all meals, the Dietary Manager delivered the sandwich, informed staff that the resident needed help eating, and then was diverted to another resident’s emergency. Video showed no staff entering the room for about 24 minutes, after which a CNA found the resident unresponsive with food leaking from his mouth and part of the sandwich in his hand. EMS, already on-site for another call, found the resident pulseless and apneic with his airway completely obstructed by emesis containing food material, which they suctioned before continuing resuscitation and transport to the hospital, where the resident was later pronounced deceased.
A resident with ESRD, bilateral amputations, dysphagia, impaired cognition, and a mechanical soft diet required staff assistance with eating and had documented dysphagia monitoring interventions. On the night in question, an LVN informed the resident’s RP that the Dietary Manager would bring food, and the Dietary Manager later delivered a sandwich and banana, placing the tray out of the resident’s reach and telling him a CNA would assist. Video showed no staff entering the room for about 24 minutes until a CNA found the resident unresponsive, with half a sandwich in his hand and food at the side of his mouth. EMS, already on site for another resident, documented a completely obstructed airway with large white, creamy chunks consistent with food suctioned from the mouth, airway, and vocal cords, and stated it was very likely the resident had been choking prior to cardiac arrest. The RP voiced concerns that the resident had choked and that staff response and lack of supervision during eating may have contributed, but the Administrator and DON concluded the event was cardiac arrest and not neglect‑related, and did not report the alleged neglect or suspicious death to the State Agency within the required 2‑hour timeframe, contrary to reporting requirements and facility policy.
A resident with Alzheimer's and other health conditions experienced significant weight loss and dehydration due to the facility's failure to implement dietary recommendations and monitor nutritional status. Despite dietary recommendations, the facility did not ensure the resident received adequate nutrition, leading to hospitalization. Staff interviews revealed poor communication and documentation regarding the resident's food intake and weight loss, contributing to the deficiency.
A resident with Alzheimer's and other conditions experienced significant weight loss, but the facility failed to update her MDS to reflect this change. Despite family concerns and reports of uneaten food, the resident became severely malnourished and dehydrated. The MDS nurse, working remotely, was unaware of the weight loss, and the facility's policy for notifying changes in condition was not followed.
The facility failed to provide adequate pharmaceutical services, as the medication room door was often left open, and expired medications and gastrostomy feedings were found. A resident with multiple health issues did not receive prescribed IV antibiotics, and expired gentamicin was found in the medication fridge. Staff interviews revealed lapses in adherence to medication storage policies.
The facility failed to comply with food safety standards, as expired food items were found in the walk-in cooler and cases of frozen food were stored on the floor. The Dietary Food Service Manager acknowledged these issues, which violate the facility's policies on food labeling, dating, and storage.
Odor in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 6 rooms reviewed for environment. Surveyors observed the hallway leading to the conference room and the conference room on 06/10/2026 at 07:48 a.m. and noted a musty, moldlike odor. The report also identified that Resident #1 and Resident #2 were in rooms with carpet odors, and the facility failed to ensure those rooms were free of odor. During interviews, CNA A stated there was a room with an odor and that Resident #2 had been moved because the resident and family did not like the musty odor of the carpet. Resident #1 stated she was moved from room 115 to another room and said the carpet smelled like urine and feces. Resident #2's family member said they requested a room change because the carpet did not smell good and expressed concern about the odor's effect on the resident's health. Housekeeping and nursing staff stated it was housekeeping's responsibility to clean carpets and address odors, and the ADM acknowledged that room [ROOM NUMBER] had an odor. The facility's cleaning procedure referenced CDC guidance for carpet cleaning, and the facility policy stated housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Failure to Care Plan and Supervise High-Risk Dysphagia Resident During Meal
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s dysphagia, history of choking, and need for assistance and supervision with eating. The resident was an older male with end-stage renal disease, bilateral lower extremity amputations, Type II diabetes, dysphagia, impaired cognition, reduced mobility, and dependence on dialysis. His records showed he required partial to moderate assistance with eating, had limited upper extremity range of motion, and was dependent for most mobility tasks. A prior progress note documented an episode of coughing and possible choking while being assisted with breakfast, after which the NP ordered a mechanical soft diet and a speech evaluation. The resident’s responsible party later requested that he be supervised during meals at all times due to choking concerns, and the NP requested monitoring during meals for safety. Despite these documented issues, the resident’s care plan did not include a specific focus area for dysphagia, prior choking history, or the responsible party’s concern for monitoring during feeding. The care plan contained a general focus on potential nutritional problems and an ADL self-care deficit, with interventions such as monitoring for signs of dysphagia and providing partial/moderate assistance with eating, but it did not clearly identify the resident’s choking risk or the need for continuous supervision during meals. Staff interviews revealed inconsistent understanding of the resident’s needs: some staff believed he only required tray setup and could eat finger foods independently, while others reported routinely feeding him because he became weak or tired and could fall asleep while eating. The MDS Coordinator stated that if she had been aware of the resident’s choking history and active dysphagia diagnosis, these should have been reflected in the care plan with appropriate goals and interventions. On the night of the incident, the dietary manager spoke with the responsible party, who was upset that the resident had not eaten after returning from dialysis. The dietary manager went to the resident’s room, observed two untouched trays, and the resident requested a turkey sandwich with cheese and mayonnaise. She removed the old trays, informed the assigned CNA that the resident would need assistance with eating, and later returned with the sandwich and a banana, placing the tray on the bedside table. She stated the tray was not within the resident’s reach and that she told him the CNA would be in shortly to assist. Video footage showed the dietary manager entering and leaving the resident’s room with a tray, and then no staff entering the room again until a CNA went in approximately 24 minutes later. When the CNA entered to feed him, she found the resident unresponsive, with food sliding from his mouth and half of a sandwich in his hand. EMS, already on-site for another resident, responded and documented that the resident’s airway was completely obstructed by large amounts of emesis containing large white, creamy chunks that appeared to be food material, which they suctioned from his mouth, airway, and vocal cords. The facility also failed to implement the existing care plan intervention for assistance with eating and monitoring for signs of dysphagia at this meal, as the resident was left alone with the sandwich and not continuously supervised while eating.
Removal Plan
- Held an emergency AD HOC QAPI meeting to discuss the issues
- Informed the Associate Medical Director
- Conducted in-services on therapeutic diet orders
Failure to Supervise High-Risk Resident During Meal Leading to Choking Event
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision during eating for a resident with known dysphagia and prior choking episodes. The resident was an older male with end-stage renal disease, bilateral lower extremity amputations, type II diabetes, dysphagia, severe cognitive impairment (BIMS 7/15), limited upper extremity range of motion, and dependence on others for most mobility. Records showed he required partial/moderate assistance with eating, had documented episodes of coughing and possible choking while being assisted with meals, and had a diet order for a regular diet with mechanical soft texture and thin liquids. Progress notes documented that the NP changed his diet to mechanical soft after a choking incident, requested a speech evaluation, and directed that he be monitored during meals for safety. The resident’s responsible party had requested that he be supervised during meals at all times due to prior choking incidents and concerns that he could not feed himself without staff assistance. On the night of the incident, the resident had returned from dialysis and initially declined food. Later, the responsible party contacted the facility expressing concern that he had not eaten, and the nurse called the responsible party from the resident’s room on speakerphone so they could speak directly. The nurse informed the responsible party that the Dietary Manager would bring food and instructed the assigned CNA to assist the resident with the meal when it arrived. The Dietary Manager, who had just conducted an in-service on diet textures and customer service, spoke with the responsible party by phone and then went to the resident’s room, where she observed two untouched meal trays. The resident told her he was hungry and requested a turkey sandwich with cheese and mayonnaise. The Dietary Manager removed the old trays, told the resident she would bring the sandwich, and informed the CNA that the resident would need assistance with eating. The Dietary Manager returned with the sandwich and a banana, placed the tray on the bedside table, and reported that it was not within the resident’s reach. She stated the resident requested a soda, and she told him she would get one and that the CNA would be in shortly to assist him with eating. Before she could return, she was diverted to another resident (her mother) who was complaining of chest pain, and she remained there while that resident was assessed and EMS was called. Video footage showed the nurse leaving the resident’s room, the Dietary Manager entering with a meal tray and leaving a few minutes later, and then no staff entering the resident’s room again until approximately 24 minutes later, when the CNA entered and found the resident unresponsive. The CNA observed food sliding from the side of his mouth, half of a sandwich in his hand, and a tray with the other half of the sandwich pushed away from the bed. EMS, already on-site for the other resident, responded and found the resident unresponsive, pulseless, and apneic with his airway completely obstructed by large amounts of emesis containing large white, creamy chunks that appeared to be food material. EMS suctioned food from the airway and vocal cords, initiated CPR and intubation, and transported the resident to the hospital, where he was later pronounced deceased. The facility did not have policies provided to surveyors that addressed supervision of residents during meals, and key staff, including the Administrator and some clinical leaders, stated they were not aware of prior choking incidents and believed it was safe to leave the resident alone with finger foods, despite documentation and family reports indicating a need for supervision during meals.
Failure to Timely Report Suspicious Death and Alleged Neglect Involving Choking and Cardiac Arrest
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged neglect-related incident and suspicious death to the State Agency within the required 2‑hour timeframe after an allegation or suspicion was formed. A male resident with end‑stage renal disease, bilateral lower extremity amputations, type II diabetes, dysphagia, impaired cognition (BIMS 7/15), reduced mobility, and need for assistance with personal care and eating was dependent on staff for transfers and required partial/moderate assistance with eating. His care plan and dietary assessments documented a mechanically altered, mechanical soft diet with thin liquids, monitoring for dysphagia signs (including choking), and staff assistance with eating due to weakness, dysphagia, and impaired cognition. An undated dashboard entry also instructed staff to assist the resident in eating due to inability to see. At a care plan meeting earlier in the month, the responsible party (RP) had voiced concerns that the resident was not being fed despite her ordering food, and the facility had indicated CNAs would attempt to feed him. On the evening of the incident, the assigned LVN spoke with the RP, who asked about ordering food; the resident declined delivery, and the LVN told the RP that the Dietary Manager was preparing food for the resident. The LVN then informed the assigned CNA that the Dietary Manager was bringing food and that the resident would need assistance with eating. Video footage later showed the LVN entering and exiting the resident’s room, followed by the Dietary Manager entering with a meal tray and leaving a few minutes later, with no other staff entering the room for approximately 24 minutes until the CNA went in. The Dietary Manager reported that she had found two untouched trays earlier, that the resident requested a turkey sandwich with cheese and mayonnaise, and that she removed the old trays, prepared the sandwich, and returned with the sandwich and a banana. She stated she placed the tray on a bedside table near the door, out of the resident’s reach, told him she would get a soda, and informed him that the CNA would be in shortly to assist with eating, but she was then diverted to another resident (her mother) with chest pain and remained there while EMS responded. When the CNA later entered the resident’s room to feed him, she observed a tray with half a sandwich pushed away from the bed, the other half of the sandwich in the resident’s hand, food sliding down the side of his mouth, and no response, respirations, or palpable pulse. Staff initiated CPR and EMS, who were already in the building for another resident, were brought to the room. EMS documented that the resident’s airway was completely obstructed by emesis, with large white, creamy chunks suctioned from the mouth, airway, and vocal cords, which EMS described as appearing to be food material, and EMS stated it was very likely the resident had been choking prior to cardiac arrest. Hospital records noted he arrived with CPR in progress and was later pronounced deceased. The RP reported to staff and EMS that she believed the resident had choked and expressed concerns about the staff’s response and the lack of supervision during eating, and EMS relayed to her that choking was suspected. Despite the RP’s expressed concerns, the resident’s known need for assistance with eating, the presence of food in his hand and mouth, and EMS’s findings of food‑like material obstructing the airway, the Administrator and DON concluded the resident had experienced cardiac arrest (or possibly pulmonary embolism), did not consider the death suspicious or neglect‑related, and determined the event was not reportable. As a result, the facility did not report the alleged neglect or suspicious death to the State Agency within the required 2‑hour timeframe, contrary to federal requirements and the facility’s own policy that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately within prescribed timeframes.
Failure to Maintain Nutritional Status Leads to Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, resulting in significant weight loss and severe dehydration. The resident, who had Alzheimer's disease, cognitive communication deficit, prediabetes, and chronic kidney disease, experienced a 19.7% weight loss over a three-month period. Despite dietary recommendations for supplements and increased caloric intake, the facility did not implement these measures, leading to the resident's admission to the hospital with hypernatremia and generalized weakness. Interviews with facility staff revealed a lack of consistent monitoring and documentation of the resident's food intake and weight loss. Nurses and CNAs were not adequately informed or did not take action regarding the resident's refusal to eat and significant weight loss. The dietician's recommendations were not communicated effectively to the physician, and there was no follow-up to ensure these recommendations were implemented. Additionally, the facility's documentation did not reflect the resident's declining nutritional status, and there was no significant change in the Minimum Data Set (MDS) despite the resident's weight loss. The facility's failure to address the resident's nutritional needs was compounded by poor communication among staff, the physician, and the resident's family. The family expressed concerns about the resident not being fed adequately, and there were instances where uneaten food trays were left in the resident's room. Despite these concerns, the facility did not hold timely care plan meetings to address the resident's weight loss and nutritional needs. The lack of coordination and communication among the interdisciplinary team contributed to the resident's deteriorating condition.
Removal Plan
- Identification of Residents Affected or Likely to be Affected: All patients in the building were evaluated for weight loss. 6 patients are on the weight loss watchlist. Dehydration Risk Assessments have been completed.
- Actions to Prevent Occurrence/Recurrence: All facility staffing policies and procedures were reviewed/revised. The Administrator reviewed and revised the Facility Assessment. AD HOC QAPI meeting was held. Findings from AD HOC QAPI will be reported at the monthly QAA meeting for a minimum of 3 months.
- Staff was in-serviced on HHSC Feeding Assistant Training Manual. Staff included CNA's, MA's, Dietary, and Therapy department. Further staff will receive training before they are allowed to work. Dietary Manager provided the training.
- Any patient that is identified with an issue related to feeding or hydration will be reported to the charge nurse. The charge nurse will report to provider. It is reported using a dietary concerns form that is available at the nursing station.
- Patients that are on the watchlist have monitoring in the MAR for the nurse to chart the amount of their meal consumed. MAR is reviewed/monitored by interim Don/Designee. MD informed of the monitoring.
- When the weekly weights are taken any patient that flags will be reviewed by interim Don/Designee and RD and added to the watchlist. interim Don/Designee will add to MARS.
- If the patient flags for weight loss, they are placed on weekly weights. The interim Don/Designee will provide the list to the Director of Rehab and the weights will be taken by the therapy department.
- Dietician's recommendations will be sent to the interim Don/Designee and the LNFA/Designee. This will ensure that interim Don/Designee and the LNFA/Designee know when they were received and forwarded to the Provider.
- Dietician's recommendations will be sent to the providers to be approved or denied. interim Don/Designee will implement the orders and notify the Dietician if they have been approved or denied. This process to be completed in no more than 72 hours.
- Dietician was notified of the watchlist. Dietician has reviewed them, and recommendations/progress notes received.
- interim Don/Designee and dietary manager will be trained by the LNFA.
Failure to Update MDS for Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, leading to a deficiency in care. The resident, who had Alzheimer's disease, cognitive communication deficit, prediabetes, and chronic kidney disease, experienced a significant weight loss from 87.2 lbs to 71.6 lbs over a month. Despite this, the MDS was not updated to reflect the resident's significant change in weight, and no significant change MDS was provided. This oversight placed the resident at risk of not receiving appropriate care and services to meet her needs. Interviews and record reviews revealed that the resident's family member (FM) frequently found uneaten food left on the resident's table, indicating that the resident was not being fed as required. The FM reported these concerns to the facility staff, but the issues persisted. The FM eventually called 911 when she found the resident severely malnourished and dehydrated, weighing only 50 lbs at the hospital. The facility's Social Services Director (SSD) and Dietician were aware of the resident's weight loss, but there was a lack of follow-up and communication with the physician to address the issue. The MDS nurse, who worked remotely, was unaware of the resident's weight loss until after discharge, as the weight loss was not noted in the 24-hour report. The facility's Administrator stated that it was the dietician's responsibility to review residents' weights weekly and document any weight loss, but the MDS nurse was responsible for updating the MDS and care plans. The facility's policy required prompt notification of changes in a resident's condition, but this was not adhered to, resulting in the deficiency.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, as evidenced by several deficiencies observed during the survey. The medication room door was frequently left open, compromising the security of medications and increasing the risk of unauthorized access. This was observed on multiple occasions, with staff acknowledging that the door should remain closed to prevent unauthorized entry. Additionally, expired medications and gastrostomy feedings were found in the medication room, indicating a lack of proper inventory management and oversight. A specific case involved a male resident with multiple diagnoses, including myopathies, pressure ulcers, end-stage renal disease, and heart disease, who was supposed to receive IV antibiotics for a wound infection. However, the medication administration records for June and July did not show that the resident received the prescribed gentamicin IV. Furthermore, a bag labeled with the resident's name containing expired gentamicin was found in the medication fridge, suggesting a failure in administering the medication as ordered. Interviews with staff, including RNs and the DON, revealed that there was a lack of adherence to policies regarding medication storage and expiration checks. The pharmacist, who was responsible for drug regimen reviews and checking for expired medications, had last visited the facility in July. The facility's policy stated that medications should be stored according to manufacturer recommendations and only authorized personnel should have access to them, but these protocols were not consistently followed, leading to the observed deficiencies.
Food Safety and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Expired food items, including high protein supplement drinks and various prepared foods such as chocolate pudding, cream of mushroom soup, chicken gravy, and spaghetti sauce, were found in the walk-in cooler. These items were not discarded by their respective use-by dates, which is a violation of the facility's food safety policies. Additionally, the facility's policy requires that potentially hazardous leftover foods be properly covered, labeled, dated, and refrigerated immediately, and discarded after 96 hours unless otherwise indicated. Furthermore, the facility did not maintain proper food storage practices, as evidenced by cases of frozen orange juice and frozen okra being stored directly on the floor in the walk-in freezer. This practice is contrary to the facility's policy, which mandates that food be kept off the floor. The Dietary Food Service Manager acknowledged these lapses during an interview, stating that leftover food should have been used or discarded before the use-by date and that food cases should not be stored on the floor.
What surveyors are citing around you — mapped
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Illustrative
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.
Illustrative
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Illustrative
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Nursing homes near Missouri City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Quail Valley Post-acute Healthcare | 0.6 mi | ★★★★★ | 6 | 0 |
| Park Manor Of Quail Valley | 1.4 mi | ★★★★★ | 0 | 0 |
| Paradigm At First Colony | 2.4 mi | ★★★★★ | 8 | 0 |
| Ignite Medical Resort Sugar Land, Llc | 4.6 mi | ★★★★★ | 7 | 0 |
| Sugar Land Health Care Center | 5.2 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.