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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Continuing Care At Eagles Trace during CMS and state inspections, most recent first.
Kitchen Food Safety and Sanitation Deficiencies: Surveyors observed a delivery driver and a chef in the kitchen prep area without hair restraints, despite staff acknowledging that hair coverings were required to prevent cross contamination and infection control issues. Surveyors also observed a small transparent container in the dry storage room holding multiple insects and 1 live insect in the same area. The DON, Dietary Services Manager, and Administrator all confirmed that hair restraints were expected for anyone in the kitchen, and facility policies stated hair nets and caps were to be worn at all times.
A resident with dementia and other diagnoses was observed fully unclothed in the shower while receiving ADL care from a private caregiver after a PA and a C.N.A. entered the room. The resident’s care plan did not indicate that the bathroom door should remain open, and both staff later acknowledged that the bathroom door should have been closed to protect privacy and dignity. RN and DON interviews confirmed that residents were expected to remain covered during shower care and that staff were responsible for maintaining privacy.
Failure to provide timely incontinent care left a dependent resident with urine-soaked clothing, linens, and brief. The resident had severe cognitive impairment, was totally dependent for ADLs, and was identified as incontinent and dependent on staff for continence care. Observation showed the brief was heavily soiled and the wet indicator was fully faded, while staff said rounds were supposed to occur every 2 hours but were not consistently completed.
A resident with impaired cognition, weakness, gait and mobility issues, neuropathy, arthritis, and a care plan requiring one-person physical assistance and a shower chair/stool was left unattended during a shower. The resident said the CNA left her alone, she called out for help and pushed the call light before RN A responded, and she did not feel safe because she could not get in and out of the shower by herself. The CNA said she was in the room making the bed while the resident showered, while an LVN stated staff should be right at the resident’s side during showers as a safety precaution.
Improper Peri Care During Incontinent Care: A resident with severe cognitive impairment and total ADL dependence received incontinent care from a CNA who did not separate the labia and wiped from back to front during peri care. The surveyor intervened before barrier cream was applied, and the area then revealed a significant amount of yellow substance on the wipes. The LVN, CNA, and DON all stated the care should have been provided front to back with the labia separated to prevent contamination and infection.
Pest control was not maintained effectively in the kitchen dry storage room when a clear container of apple cider vinegar used as a fruit fly trap was found with several small insects inside, and one live insect flew away when it was removed. The DSD, GM of Dietary Services, Maintenance Director, and Administrator all acknowledged the issue, and the facility’s Integrated Pest Management policy called for prevention, monitoring, control, and staff education.
The facility failed to follow professional standards for food safety, including improper labeling and dating of food items, and inadequate storage practices. Observations revealed unlabeled blue cheese, expired Swiss cheese and mushrooms, and food stored on the floor in the freezer. Scoops were improperly left in bulk food bins, violating facility policies.
The facility failed to properly dispose of garbage in one of its dumpsters, with a bag of garbage left on top of the lid instead of inside. The General Manager of Dining Services confirmed that the dumpster doors should be kept closed to prevent pests. The responsibility for proper disposal was shared among dietary staff, nursing, and housekeeping. Facility policies indicated that trash should be secured and deposited in the designated dumpster.
A resident with a suprapubic catheter was found with unsecured tubing, contrary to the facility's policy requiring a statlock to prevent dislodgement. Despite staff training, the CNA was unaware of the issue, and the nurse responsible did not ensure compliance. The DON confirmed the necessity of securing catheter tubing to prevent injury.
A resident receiving IV antibiotic therapy for cellulitis was found to have expired cefepime in the medication room fridge. Despite the facility's policy on medication management, the expired medication was not discarded, potentially affecting the resident's treatment. Interviews with the ADON and DON indicated that nurses are expected to check for expired medications, but the expired cefepime was not identified and removed.
The facility failed to maintain an infection prevention and control program, as infection control gowns and pillows were found on the floor in two storage rooms. Interviews revealed that staff were unaware of the requirement to keep these items off the floor. The facility's policy mandates maintaining a clean and orderly environment, which was not adhered to.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. During observation on 9/17/25 at 11:51 AM, a delivery driver was seen in the kitchen preparation area without a hair restraint. Shortly after, at 11:54 AM, Chef A was observed in the food preparation area without a hair restraint. Chef A stated he was aware hair restraints were important to avoid cross contamination and for infection control, and said the negative outcome could be someone getting sick. At 11:55 AM, the General Manager of Dietary Services observed the same issue and stated that everyone in the kitchen should have on a hairnet or hair restraint to prevent cross contamination and infection control concerns; Chef A then placed on a hair restraint. On 9/18/25 at 12:20 PM, the DON stated that all staff in the kitchen were responsible for avoiding cross contamination and following infection control practices, and that a negative outcome could be foodborne illness. On 9/18/25 at 2:30 PM, the Dietary Services Manager reviewed the facility policies on Uniform Dress Code and Food Handlers - Employee Health and stated the purpose of hair restraints was to prevent cross contamination and infection control issues, and that the facility followed the Texas Food Code. During the same survey, a small transparent square container in the dry storage room was observed holding multiple insects, and 1 live insect was also observed in the dry storage room. The Administrator later stated that all staff were expected to wear hair restraints when in the kitchen to avoid cross contamination and infection control concerns.
Resident Exposed During Shower Care
Penalty
Summary
The facility failed to ensure Resident #17’s privacy during showering when staff entered and observed the resident fully unclothed while she was receiving ADL care from her private caregiver. Resident #17 was a female resident admitted with diagnoses including dementia, severe behavioral psychosis mood disorder, obsessive compulsive disorder, muscle weakness, unspecified lack of coordination, and anorexia. Her MDS reflected a BIMS score of 13, suggesting intact cognition, and her care plan did not indicate that her bathroom door was to remain open during showers. During observation, Program Assistant A knocked, opened the resident’s room door, and quickly closed it after placing a paper on a dresser near the entrance. Shortly after, C.N.A. A was observed knocking, entering, and exiting the room. At 9:48 a.m., Resident #17 was observed in the shower, fully unclothed, while receiving a shower from her personal caregiver. C.N.A. A later stated she had entered the room while the resident was showering and saw the resident nude, and she acknowledged that the bathroom door should have been closed to maintain dignity and respect. Program Assistant A stated she opened the door to announce herself and immediately saw the resident naked in the shower, then closed the door. RN A stated that no matter whether a private staff member or facility staff assisted with a shower, the resident was not to be exposed, and that all staff were responsible for ensuring privacy during ADL care. The DON stated the bathroom door should be closed during showering unless the resident’s preference had been care planned, and the Administrator stated staff were expected to provide privacy and preserve dignity based on the resident’s preferences. Training records reviewed reflected in-services on showers, privacy, dignity, and resident preferences.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received necessary assistance with grooming and personal hygiene. Resident #3, a female with diagnoses including diabetes mellitus, cerebral infarction, and dysphagia, had a quarterly MDS showing a BIMS score of 4 out of 15 and was totally dependent on staff for all ADL care with one to two staff assist. Her care plan identified that she was incontinent of bowel and dependent on staff for care, including assistance with garments and continence products. During observation, Resident #3 was found lying in bed with her pants, draw sheet, a towel placed on top of the draw sheet, and bed linen wet with urine, and the incontinent brief was brown inside with the wet indicator completely faded out. Staff interviews indicated CNA K was expected to provide incontinent care and make rounds every two hours, including at the start of the shift and around meals, but she stated she had changed the resident after breakfast and was behind that morning because the shift was fast-paced. The DON and Administrator stated the resident should have been checked more often because she was a heavy wetter, and the facility's urinary incontinence management stated brief changes were to occur every 2 to 4 hours with cleansing, rinsing, drying, and skin inspection.
Inadequate Supervision During Shower Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during bathing for one resident who required one-person physical assistance and a shower chair/stool. Resident #25’s care plan identified bathing needs that included help getting in and out of the shower/tub, washing hair, washing the back, washing the legs/feet, applying lotion, and drying, and the resident’s MDS reflected a BIMS score of 09, indicating moderately impaired cognition. The resident also had diagnoses including muscle weakness, gait and mobility abnormalities, neuropathy, poly osteoarthritis, lack of coordination, anemia, and cognitive communication deficit. During an interview, the resident stated that while receiving a shower, she was left alone by C.N.A. B and was ready to get out when she called for help. She reported calling out several times, then yelling for help, but no one responded, so she pushed the call light and RN A entered the room, followed by C.N.A. B. The resident stated she could not get in and out of the shower by herself, did not want to be left alone, and did not feel safe. She also stated that if she fell in the shower, it would be difficult to crawl to the call light cord to summon help. C.N.A. B stated she gave the resident a shower and, while the resident showered herself, she changed the resident’s bed sheets and made the bed. She stated she was in the room at the resident’s bed and did not consider the resident to have been left alone in the shower. LVN C stated she entered the room because the call light had been going off and saw the resident in the shower while C.N.A. B was in the room; she stated staff should be right at the resident’s side during showers as a safety precaution and that it was not her professional experience to make the bed while the resident was showering. The Administrator stated it was her expectation that staff provide adequate supervision so the resident is safe and feels safe while receiving ADL assistance.
Improper Peri Care During Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a female resident who was totally dependent on staff for all ADL care and had diagnoses including diabetes mellitus, cerebral infarction, and dysphagia. Her quarterly MDS showed a BIMS score of 4 out of 15, indicating severely impaired cognition. Her care plan stated that she was incontinent of bowel and dependent on one staff member for care, including assistance with garments and continence products. During observation, CNA K provided incontinent care but did not separate the resident’s labia when cleaning the peri area and wiped from back to front. The CNA was about to apply barrier cream when the surveyor intervened; at that point, the labia were separated and the area was wiped three times, revealing a significant amount of yellow substance on the wipes. In interviews, the LVN, CNA K, and DON all stated that the resident should have been cleaned from front to back and that the labia should have been separated during peri care to prevent contamination and infection. The facility’s urinary incontinence management guidance stated that skin cleansing, rinsing, drying, and inspection should occur during pad or brief changes.
Pest Control Program Not Maintained in Dry Storage Area
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen environment, specifically in the dry storage room. During observation on 9/16/25 at 8:35 AM, a small clear square container with clear light brown liquid was found in the dry storage room and was identified by the Director of Dietary Services as apple cider vinegar being used as a fruit fly contraption. Several small insects were observed in the container, and one live insect flew away when the container was removed. The Director stated the contraption was not supposed to be there. During interviews, the General Manager of Dietary Services stated she had been made aware of the container with vinegar and fruit flies and said the fruit flies came with the summer heat, but that the contraption should not have been there. The Maintenance Director stated pest control came every Wednesday and as needed by request, and that the facility had not had any major issues with fruit flies. The Administrator stated that any pest around food could cause contamination and that she was responsible for pest control oversight while general services managed the contracts. Record review showed the facility policy for Integrated Pest Management, dated 3/17/2025, included prevention, monitoring, control, and education related to pests.
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. Specifically, the facility did not ensure that foods were properly labeled with dates when opened or prepared, and did not discard them after 72 hours as required. During the inspection, a plastic container of blue cheese was found without a label or use-by date, and a container of sliced Swiss cheese and a case of fresh sliced mushrooms were found with use-by dates that had already passed. These oversights in food labeling and dating could potentially lead to the use of expired food items. Additionally, the facility did not maintain proper food storage practices. Several cases of food, including wheat bread, breaded chicken, ice cream cups, and sausage, were stored directly on the floor in the walk-in freezer, contrary to the facility's policy that requires food to be stored at least six inches above the floor. Furthermore, scoops were left inside bins of cornbread, flour, and sugar, instead of being stored separately in a holder as per the facility's procedures. These storage failures could increase the risk of contamination and compromise food safety.
Improper Garbage Disposal in Facility Dumpster
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in one of the two dumpsters reviewed for Food and Nutrition Services. During an observation, a commercial-sized dumpster located behind the dietary department was found to be three-quarters full, with a bag of garbage left on top of the dumpster lid instead of inside. In an interview, the General Manager of Dining Services acknowledged that the garbage bag should have been placed inside the dumpster and emphasized the importance of keeping the dumpster doors closed to prevent vermin, pests, and insects from accessing the garbage and potentially entering the facility. The responsibility for ensuring proper disposal and closing of the dumpster doors was shared among dietary staff, nursing, and housekeeping. A review of the facility's waste disposal policies, dated June 2023, indicated that trash container liners should be secured, collected, and deposited in the designated dumpster.
Failure to Secure Suprapubic Catheter Tubing
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, which is necessary to prevent urinary tract infections and ensure the resident's safety. The resident, a 90-year-old male with severe cognitive impairment and a history of hemiplegia, dysarthria, and benign prostatic hyperplasia, was observed with unsecured catheter tubing, which could lead to dislodgement. The facility's policy requires the use of a statlock to secure the catheter tubing, but this was not done for the resident. Interviews with staff revealed a lack of awareness and adherence to the facility's policy. A CNA, who had been trained on catheter care, was unaware that the resident's catheter was not secured. The nurse responsible for the resident acknowledged the policy requirement but failed to ensure compliance. The Director of Nursing confirmed that securing catheter tubing is necessary to prevent injury. The facility's policy, dated July 2021, mandates securing suprapubic catheters to prevent accidental dislodgement, which was not followed in this case.
Expired Medication Not Discarded
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the expiration date of medications. This deficiency was observed in the case of a resident who was receiving intravenous antibiotic therapy with cefepime for cellulitis. The medication, which was stored in the medication room fridge, was found to have expired on 08/14/2024, yet it was still present and available for administration on 08/15/2024. This oversight could potentially compromise the effectiveness of the antibiotic therapy being administered to the resident. The resident involved was an elderly female with a diagnosis of cellulitis and lymphedema, who was receiving cefepime 1 gram intravenously every 8 hours as part of her treatment plan. Despite the facility's policy on medication management, which includes proper storage and checking for expired medications, the expired cefepime was not discarded. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that nurses are expected to check for expired medications, and audits are conducted in the medication room. However, the expired medication was not identified and removed in a timely manner.
Infection Control Deficiency: Items Found on Floor
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the presence of infection control gowns and pillows on the floor in two storage rooms. During an observation of the laundry room and linen closets, two yellow gowns were found on the floor of Room A, and three blue plastic resident pillows were on the floor of Room B. Interviews with the Facility Manager and the Director of Housekeeping revealed that they were unaware of the requirement to keep these items off the floor. The Administrator suggested that the items might have fallen from the shelves, while the Director of Nursing confirmed that the items should not have been on the floor, as everything should be elevated to prevent infection. The facility's policy, dated May 2021, mandates maintaining a clean and orderly environment, which was not adhered to in this instance.
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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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How nearby facilities compare on the same public inspection record.
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| Avir At Houston | 1 mi | ★★★★★ | 27 | 2 |
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| Focused Care At Beechnut | 4.2 mi | ★★★★★ | 1 | 1 |
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