Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Beechnut during CMS and state inspections, most recent first.
A cognitively impaired male with Alzheimer’s disease, identified as a high elopement risk and residing on a secure unit, eloped after removing a window and fence planks without staff detection. He had a very low BIMS score and had repeatedly expressed a desire to go home to the Activity Director, but key management staff reported being unaware of these exit-seeking statements. On the day of the incident, CNAs last saw the resident around dinner time near his room, and staff relied on two-hour rounds and an aide seated in the living area to monitor exits. The resident was discovered missing when a medication aide attempted to pass meds and could not find him anywhere in the building; investigation showed he had exited through a window into a courtyard and then through an opening in an old fence. He was later found by the Activity Director approximately 2.5 miles away in front of a store on a busy street.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite having a wander guard. She was last seen during dinner and was found the next day in a hospital with heat exhaustion. Staff did not hear any alarms, and the exact method of her exit is unknown. The facility had experienced power outages, which may have affected the alarm system.
A facility failed to notify a physician and a resident's representative of a change in the resident's condition, leading to an Immediate Jeopardy situation. The resident, with neuromuscular dysfunction of the bladder and hemiplegia, had an indwelling catheter and developed a slit on the penis that was not documented or reported in a timely manner. The facility also failed to ensure the resident attended scheduled urologist appointments, contributing to the worsening of the condition.
A facility failed to provide proper care for residents with indwelling catheters, leading to deficiencies in preventing urinary tract infections. A resident with a history of neurogenic bladder and chronic kidney disease had a significant slit in the penile area due to prolonged Foley catheter use, which was not adequately assessed or followed up. Staff failed to adhere to infection control protocols, not changing gloves or performing hand hygiene during care. Another resident experienced inadequate care as CNAs placed the Foley bag on the bed, highlighting significant lapses in care practices.
The facility failed to maintain resident dignity and privacy, as evidenced by a CNA standing while feeding a resident, an LVN administering insulin without privacy, and an RN administering G-tube medications without privacy. These actions violated facility policies on meal service and resident rights, which emphasize dignity and privacy.
A facility failed to develop a comprehensive care plan for a resident receiving anticoagulants, lacking measurable objectives and interventions. The resident, with anemia and hemiplegia, was administered Apixaban without a corresponding care plan. The MDS Coordinator acknowledged the oversight, highlighting the importance of care plans in guiding resident care.
The facility failed to comply with food safety standards, as expired foods were not discarded, and several food items lacked proper labeling. Additionally, improper thawing procedures for frozen fish fillets were observed, with the fish found in the danger zone for food safety. A scoop was also left in the ice maker bin, violating facility policy. These deficiencies could risk residents' health.
The facility failed to properly dispose of garbage and refuse for two dumpsters used by the Food and Nutrition Services. Both dumpsters were observed to be three-quarters full with their doors open, contrary to the facility's policy requiring them to be closed to prevent pest access. The Food Service Manager confirmed the responsibility for proper waste disposal was shared among dietary, nursing, and housekeeping staff.
A facility failed to maintain an effective Infection Prevention and Control Program, with deficiencies observed in resident care and laundry practices. A CNA did not change gloves or perform hand hygiene during catheter and incontinent care, risking cross-contamination. Additionally, improper storage of clean linens and a broken soap dispenser in the laundry room further compromised infection control standards.
A resident with mild cognitive impairment was found with a disposable razor and hygiene products unsupervised in his room, posing a potential risk. Staff interviews confirmed these items should not have been left accessible, and the facility's policy did not specifically address the safety of such personal items.
A resident with Alzheimer's and dysphagia experienced a choking episode, but the LTC facility failed to promptly notify the physician and the resident's representative. Despite staff awareness of the incident, the facility did not follow its policy on change of condition notification, contributing to a deficiency identified by surveyors.
A resident with dysphagia at an LTC facility did not have a comprehensive care plan addressing her condition, leading to two choking incidents and eventual hospitalization. Despite staff being informed of the initial choking episode, no immediate changes were made to the care plan or dietary orders. The MDS Nurse was unaware of the resident's condition, and the DON had not trained staff on recognizing signs of aspiration, contributing to the oversight.
A resident with dysphagia experienced multiple choking incidents due to inadequate supervision and intervention by the facility. Despite a previous choking episode, the facility did not update the resident's care plan or train staff on recognizing signs of aspiration and choking. The resident was not closely monitored during meals, leading to another choking incident that required emergency medical intervention and resulted in her passing away.
A resident on anticoagulant therapy experienced an unwitnessed fall resulting in a head injury, but was not immediately transferred to the hospital via emergency services. Instead, non-emergency transportation was used, delaying necessary medical evaluation. The resident, who primarily spoke Spanish, was not assessed in her primary language, and her care plan lacked specific interventions for anticoagulant therapy. The facility's staff cited a lack of active bleeding and stable condition as reasons for the delay, but the risk of internal bleeding was not adequately addressed.
A facility failed to maintain a safe environment when two CNAs engaged in a physical altercation, leading to one CNA discharging a firearm outside near resident rooms. The incident began over an unsafe resident transfer and escalated due to inadequate enforcement of workplace violence and firearm policies. The firearm was left unattended in an unsecured area, placing residents at risk.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent an elopement for one cognitively impaired resident identified as a high elopement risk. The resident was an older male with Alzheimer’s disease, cognitive communication deficit, aphasia, and hypertension, with a BIMS score of 1/15 indicating significant cognitive impairment. His care plan, initiated months earlier, identified him as a high elopement risk/wanderer and included interventions such as structured activities, toileting, walking inside and outside, reorientation strategies, and residence on a secure unit. Despite this, staff interviews revealed that key members of the management team, including the ADON, DON, and Administrator, were not aware that the resident had been expressing a desire to go home. On the day of the incident, staff observed the resident eating dinner and then walking to his room, with one CNA later seeing him standing in front of his room at approximately 6:45 p.m. Another CNA reported last seeing him around 5:30 p.m. when he took his dinner tray to his room. Staff reported that aides made rounds every two hours and that one aide was seated in the living area during dinner to ensure no resident left through the exit door. However, no staff member observed the resident manipulating or exiting through a window or leaving the facility grounds. The resident was later discovered missing at approximately 7:00 p.m. when a medication aide attempted to administer his medications and could not locate him in his room, bathroom, hallway, or elsewhere in the facility. Subsequent investigation by facility staff determined that the resident had removed a window from its frame in a room across from his own by bending long screws that held the glass, climbed out into the courtyard, and then removed two old wooden fence planks to exit the property. No staff witnessed these actions or his departure from the premises. The Activity Director, who had previously heard the resident express a desire to go home and had reported this in a morning meeting, was notified that he was missing and later located him in front of a store on a busy street approximately 2.5 miles from the facility. Multiple staff, including the ADON, DON, Maintenance Director, and Administrator, acknowledged that staff were unaware of the resident’s exit until the medication pass revealed his absence, and that he had been outside the facility unsupervised.
Resident Elopement Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to her elopement. The resident, who had severe cognitive impairment and was at risk for wandering and elopement, was last seen during dinner. Despite having a wander guard, she was able to leave the facility unnoticed. The staff initiated a search and notified the police, but the resident was not found until the following day when she was admitted to the hospital with heat exhaustion and weakness. The resident's medical history included schizophrenia, cognitive communication deficit, bipolar disorder, and blindness in one eye. Her care plan identified her as a risk for wandering and elopement, with interventions such as frequent monitoring and reorientation. However, on the day of the incident, the staff did not detect any alarms, and the resident was able to leave the facility without being noticed. The facility's elopement risk assessments showed varying levels of risk, but the resident's wander guard was reportedly functioning properly. Interviews with staff revealed that they were aware of the resident's elopement risk and had procedures in place for monitoring wander guards and responding to alarms. However, there were no alarms heard during the time the resident went missing, and the exact method of her exit was unknown. The facility had experienced power outages, which may have affected the alarm system, but this was not confirmed as the cause of the elopement.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with the physician and notify the resident representative when a resident experienced a change in condition. Specifically, the facility did not notify the physician regarding the resident's missed urologist appointments and failed to communicate the resident's changing skin condition of the groin. The resident, a 58-year-old male with neuromuscular dysfunction of the bladder and hemiplegia following a cerebral infarction, had an indwelling catheter and was at risk for urinary tract infections. Despite having orders to monitor and report changes in the resident's condition, the facility did not document or report the development of a slit on the resident's penis until it had significantly worsened. The resident's care plan included interventions to prevent catheter-related trauma and monitor for signs of urinary infection. However, the facility did not adhere to these interventions, as evidenced by the lack of documentation for the slit on the penis in the weekly skin assessments from April to June. The resident's physician orders included a urology consult and monitoring for changes in the penile area, but the facility failed to ensure the resident attended the scheduled urologist appointments. The resident did not see the urologist until June, and by that time, the slit had grown significantly, measuring 8 cm in length, 1 cm in width, and 0.4 cm in depth. Interviews with staff revealed that the facility was unaware of the urologist's office relocation, which contributed to the missed appointments. The treatment nurse identified the slit during a skin assessment but did not measure it or ensure timely follow-up. The facility's failure to notify the physician and follow up on the resident's condition led to an Immediate Jeopardy situation, as the resident's condition had the potential for more than minimal harm.
Deficiencies in Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling catheters, leading to deficiencies in the treatment and prevention of urinary tract infections. Resident #72, a male with a history of hemiplegia, neurogenic bladder, and chronic kidney disease, was observed to have a significant slit in the penile area due to prolonged Foley catheter use. The facility did not adequately assess or follow up on this condition, nor did they update the care plan or secure the catheter properly, resulting in discomfort and potential harm to the resident. Additionally, the facility's staff failed to adhere to proper infection control protocols during catheter and incontinent care. CNA B did not change gloves or perform hand hygiene while providing care to Resident #72, which could lead to cross-contamination and infection. Observations revealed that the catheter was not secured with a proper device, causing further discomfort and potential trauma to the resident. Resident #54 also experienced inadequate care, as CNAs placed the Foley bag on the bed during care, which is against proper procedure. This oversight, along with the failure to secure catheters and monitor for signs of infection, highlights significant lapses in the facility's care practices, potentially affecting the residents' health and safety.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and privacy, as evidenced by several incidents involving three residents. A certified nursing assistant (CNA) was observed standing while feeding a resident with severe cognitive impairment and multiple health issues, including Parkinson's Disease and dysphagia. The CNA admitted to standing due to the lack of a chair and acknowledged being taught to sit while feeding residents to maintain their dignity. In another incident, a licensed vocational nurse (LVN) administered insulin to a resident with severe cognitive impairment and diabetes without providing privacy by closing the door or pulling the privacy curtain. The LVN admitted to forgetting to ensure privacy during the procedure. Similarly, a registered nurse (RN) failed to provide privacy while administering medications via a gastrostomy tube to a resident with severe cognitive impairment and a history of cerebral infarction and dysphagia. The RN acknowledged the oversight, attributing it to nervousness. The facility's policies on meal service and resident rights emphasize the importance of maintaining residents' dignity and privacy. The meal service policy specifies that staff should not stand while feeding residents and should engage in conversation during meals. The resident rights policy mandates treating residents with respect, kindness, and dignity, including ensuring privacy and confidentiality. These incidents demonstrate a failure to adhere to these policies, compromising the residents' quality of life.
Failure to Implement Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was receiving anticoagulant medication. The care plan lacked documentation of measurable objectives, interventions, or timeframes to address the resident's use of anticoagulants. This deficiency was identified during a review of the resident's records, which showed that the resident was receiving Apixaban, an anticoagulant, but there was no corresponding care plan to guide staff in meeting the resident's needs related to this medication. The resident in question was a 58-year-old male with diagnoses including anemia and hemiplegia following a cerebral infarction. Despite these conditions and the administration of anticoagulants, the facility did not have a care plan in place to address the specific needs associated with the medication. The MDS Coordinator acknowledged the oversight, noting that the care plan is crucial for providing appropriate care. The facility's policy required an individualized care plan to be developed within 48 hours of admission and revised regularly, but this was not adhered to in this case.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Expired foods were not discarded, with two tubs of cottage cheese found in the walk-in cooler past their manufacturer expiration date. Additionally, several food items, including shredded cheese and sliced American cheese, were not labeled with the date they were opened or a use-by date, violating the facility's policy that requires potentially hazardous leftover foods to be properly covered, labeled, dated, and refrigerated immediately, and discarded after 72 hours unless otherwise indicated. Furthermore, the facility did not follow proper procedures for thawing frozen fish fillets. The fish was found submerged in water at a temperature of 71.8 degrees Fahrenheit, with the fish itself at 66.4 degrees Fahrenheit, which is within the danger zone for food safety. The facility's policy states that frozen food should be thawed under running water at a temperature of 70 degrees Fahrenheit or below, and the fish should be at a temperature of 41 degrees or lower. Additionally, a scoop was left in the ice maker bin, contrary to the facility's policy that scoops should not be left in food containers or bins. These failures could place residents at risk of foodborne illness and disease.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse for two dumpsters used by the Food and Nutrition Services. During an observation, it was noted that both dumpsters, labeled as A and B, were three-quarters full of garbage with their doors open. This was confirmed in an interview with the Food Service Manager, who acknowledged that the dumpster doors should always be closed to prevent vermin, pests, and insects from accessing the garbage and potentially entering the facility. The responsibility for ensuring proper disposal of food waste was shared among staff from dietary, nursing, and housekeeping departments. A review of the facility's Policies and Procedures on waste disposal, dated November 2023, indicated that food waste should be stored in a manner inaccessible to pests, and outside dumpsters should be kept closed and free of surrounding litter.
Infection Control Deficiencies in Resident Care and Laundry Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple deficiencies observed during a survey. One significant issue involved a resident who required indwelling catheter and incontinent care. During the care process, a CNA did not change gloves or perform hand hygiene, which is a critical step in preventing cross-contamination and infection. The CNA used the same gloves throughout the procedure, even after cleaning the resident's soiled areas, and did not secure the indwelling catheter properly, causing discomfort and potential harm to the resident. Additionally, the facility's laundry room practices were found to be inadequate in maintaining infection control standards. Personal items were observed on a clean folding table, and clean linens were improperly stored on the floor and in the dirty section of the laundry room. The soap dispenser in the laundry room was broken, forcing staff to leave the area to wash their hands, which could lead to further contamination. These practices pose a risk of cross-contamination and infection among residents. Interviews with staff and the Director of Nursing confirmed awareness of these issues, yet the necessary infection control protocols were not consistently followed. The facility's policies on hand hygiene and laundry handling were not adhered to, contributing to the deficiencies observed. The lack of proper hand hygiene, glove changes, and appropriate storage of clean linens highlights significant lapses in the facility's infection control measures.
Unsupervised Hazardous Items in Resident's Room
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically for one resident who was found to have a disposable razor and hygiene products unsupervised in his room. This resident, who has a mild cognitive deficit and requires supervision for personal hygiene, was observed with these items accessible in his room. The presence of these items posed a potential risk, especially considering the resident's cognitive condition and the possibility of other residents with wandering behaviors accessing the room. Interviews with staff, including a CNA and the DON, confirmed that the razor and hygiene products should not have been left in the room unsupervised. The CNA noted that the resident's family member likely brought the items into the room, and the DON acknowledged the risk posed by the items being accessible. The facility's policy on resident rights did not specifically address the safety of personal items like razors or hygiene products, contributing to the oversight.
Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to immediately consult with the physician and notify the resident representative when a resident experienced a change in condition. The resident, an 83-year-old female with Alzheimer's Disease, dysphagia, heart disease, and cerebral infarction, experienced a choking episode. Despite the resident's history and the choking incident, the facility did not inform the physician or the resident's representative promptly. The incident occurred when the resident was wheeled from the dining room to the nurse station and later found unresponsive. Although CPR was performed and 911 was called, the facility did not notify the physician or the resident's representative about the choking episode that preceded the resident's unresponsiveness. Interviews with staff revealed that the choking incident was known to some staff members, but the information was not communicated to the physician or the resident's representative in a timely manner. The facility's policy on notifying the physician and resident representative of changes in condition was not followed. The Director of Nursing admitted to not calling the physician after being informed of the choking incident, and the primary care doctor confirmed not being notified. This lack of communication and failure to follow protocol contributed to the deficiency identified by the surveyors.
Failure to Implement Comprehensive Care Plan for Dysphagia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with dysphagia, a condition characterized by difficulty swallowing. Despite the resident's diagnosis, the care plan did not address this critical medical need, leaving the resident vulnerable to choking incidents. The resident experienced a choking episode, which was not documented in the nursing progress notes, and subsequently had another choking incident that led to hospitalization and eventual death. Interviews with staff revealed a lack of communication and action following the initial choking incident. A CNA reported the choking episode to several staff members, including the DON, but no immediate changes were made to the resident's care plan or dietary orders. The CNA also informed the kitchen staff to provide soft-textured foods, but the resident continued to receive a mechanical soft diet, which was not suitable given her condition. The MDS Nurse, responsible for care planning, was unaware of the resident's dysphagia diagnosis and had not reviewed the care plan. The DON admitted to not having in-serviced the nursing staff on the signs of silent aspiration or choking, which contributed to the oversight. The facility's policy required a comprehensive care plan to be developed within seven days of the resident's assessment, but this was not adhered to, resulting in inadequate care for the resident.
Failure to Prevent Choking Incidents in Resident with Dysphagia
Penalty
Summary
The facility failed to ensure adequate supervision and intervention for a resident with dysphagia, leading to multiple choking incidents. The resident, an 83-year-old female with Alzheimer's Disease, dysphagia, and other medical conditions, experienced a choking episode during a meal. Despite this incident, the facility did not implement necessary interventions or update the resident's care plan to address her swallowing difficulties. Staff members were not adequately trained on recognizing signs of silent aspiration and choking, which contributed to the lack of appropriate response. The resident's choking episode was not properly communicated to the physician or the speech therapist, delaying necessary evaluations and interventions. Interviews with staff revealed that there was confusion and a lack of clear communication regarding the resident's condition and the appropriate steps to take following the choking incident. The resident was not monitored closely during meals, and her dietary needs were not reassessed or adjusted in a timely manner, despite staff observations of her difficulty swallowing and previous choking incidents. The facility's failure to provide adequate supervision and intervention resulted in the resident experiencing another choking episode, which required emergency medical intervention and ultimately led to her passing away at the hospital. The lack of a comprehensive care plan for the resident's dysphagia and the absence of staff training on choking and aspiration precautions were significant factors in the deficiency identified by the surveyors.
Delayed Emergency Response for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who was cognitively impaired and on anticoagulant therapy. The resident experienced an unwitnessed fall, resulting in a head injury, but was not immediately transferred to the hospital via emergency services. Instead, the resident was transported using a non-emergency service, which delayed the necessary medical evaluation and treatment. This delay in care was identified as an Immediate Jeopardy situation, indicating a serious risk to the resident's health and safety. The resident, who primarily spoke Spanish and had severe cognitive impairment, was not assessed in her primary language following the fall. This language barrier may have contributed to the inadequate assessment and delayed response to the resident's condition. The resident's care plan did not include specific interventions related to her anticoagulant therapy, which is critical given the increased risk of bleeding and complications following a head injury. The facility's staff, including the DON and Administrator, acknowledged the failure to immediately transport the resident via emergency services, citing a lack of active bleeding and stable condition as reasons for the delay. However, the risk of internal bleeding due to the resident's anticoagulant medication was not adequately addressed. Interviews with staff and family members highlighted communication issues and inconsistencies in the facility's response to the incident.
Unsafe Environment and Firearm Incident in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment free from accidents and hazards, as evidenced by a series of incidents involving two CNAs. On the morning of the incident, CNA B and CNA C engaged in a verbal and physical altercation in the presence of residents. The altercation escalated when CNA C, who had brought a loaded firearm into the facility, pointed the gun at CNA B and discharged it outside near resident-occupied rooms. This incident placed all residents at risk of serious harm or injury. The altercation began when CNA C transferred a resident, who required a two-person assist, by herself. CNA B approached CNA C to address the unsafe transfer, which led to a heated argument. Witnesses reported that the argument became physical, with conflicting accounts of who initiated the physical contact. CNA C claimed she was being bullied and brought the firearm for protection, as she traveled by bus at night. Despite signs prohibiting firearms on the premises, CNA C left the loaded gun unattended in an unsecured cabinet under the nurse's station desk. The facility's response to the incident was delayed, as the police were not immediately notified, and there was confusion among staff about the events that transpired. The facility's policies on workplace violence and firearms were not effectively enforced, contributing to the severity of the incident. The lack of secure storage for personal belongings and inadequate supervision allowed the situation to escalate, resulting in the discharge of a firearm near residents.
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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
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) |
|---|---|---|---|---|
| West Houston Rehabilitation And Healthcare Center | 0.9 mi | ★★★★★ | 2 | 0 |
| St Dominic Village Rehabilitation And Nursing Cent | 1.9 mi | ★★★★★ | 2 | 0 |
| Focused Care At Westwood | 2.6 mi | ★★★★★ | 2 | 0 |
| Avir At Houston | 3.8 mi | ★★★★★ | 17 | 2 |
| Park Manor Of Westchase | 3.8 mi | ★★★★★ | 1 | 1 |
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