Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
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 Focused Care At Humble during CMS and state inspections, most recent first.
Medications were left unsecured at the bedside for two residents. One resident with dementia and severe cognitive impairment had Tums found on the bedside table after staff initially believed the dose had been taken, and an LVN stated staff should not leave medication at the bedside. Another resident with Parkinson's disease and severe cognitive impairment had Systane eye drops on the bedside table and said he used them himself, while RN staff stated they were unaware of the drops and that medications were expected to be secured after administration.
Failure to perform hand hygiene during incontinent care. A CNA provided incontinent care to a resident with severe cognitive impairment, diabetes, immunodeficiency, and frequent bowel and urine incontinence, but did not change gloves or perform hand hygiene before touching clean items such as the brief and clothing. The DON stated staff were expected to perform hand hygiene before entering the room, between glove changes, and before exiting the room, and the facility policy required hand hygiene before and after glove use and after contact with bodily fluids.
Failure to Provide Ordered Wound Care and Sepsis Monitoring: A resident with a stage 3 sacral pressure ulcer had worsening wound measurements, cellulitis, and abnormal vital signs while ordered wound care was not consistently documented or carried out as written, including Santyl and Dakins cleanse. Sepsis monitoring was also not completed despite fever and tachycardia, and the resident was later transferred to the hospital with septic shock and a necrotizing sacral infection.
A resident with dementia, weakness, incontinence, and PVD developed a stage 3 sacral wound, but the wound was not added to the care plan even after a new coccyx open area and wound treatment orders were documented. Interviews showed the WCN, ADCO, and DCO expected wound care planning to be completed promptly, yet the wound was missed and only general skin-risk interventions were listed.
Abuse and Physical Force Toward Residents: Multiple staff members were observed using vulgar language and physical force with residents on the memory care unit. A CNA forcefully pushed one resident into a couch, slapped and pulled another resident, and grabbed two other residents by the shoulders while directing them down the hall. In a separate altercation, a laundry aide struck a resident in the face after the resident grabbed the aide's hair. Several affected residents had severe cognitive impairment, dementia, and other neuropsychiatric conditions.
A resident with seizures, epilepsy, anxiety, Parkinson’s disease, mild cognitive impairment, and autism missed four scheduled doses of clonazepam because the med was unavailable in the facility. Staff documented the med as on order or not available, and the resident later had three back-to-back seizure episodes and was sent to the hospital. Hospital records noted the presentation was most consistent with breakthrough seizures, while staff gave differing accounts about the refill process and the med’s indication.
A medication cart was found unlocked and unattended in a hallway, with a lidocaine patch and two unidentified pills left on top, accessible to residents. Nursing and administrative staff confirmed that medications and carts are expected to be locked at all times, but the lapse occurred when an RN left the cart to assist another staff member. The facility could not provide its medication storage policy when requested.
A resident with dementia and a history of wandering exited the facility unattended, despite having a wander guard device and being identified as an elopement risk. Staff interviews revealed gaps in supervision, unclear responsibilities, and confusion about elopement protocols and the wander guard system. Security measures were in place but did not prevent the resident from leaving, resulting in a deficiency related to inadequate supervision and accident prevention.
A resident experienced significant health decline, including weight loss and physical decline, without the facility notifying the physician or family. Despite interventions, the resident continued to lose weight, and the facility relied on an NP rather than involving the physician. The lack of communication led to inadequate medical interventions.
A resident with multiple medical conditions, including COPD and malnutrition, was found in a neglected state upon transfer to a hospital. The resident was covered in feces and urine, indicating a lack of personal hygiene care. Despite interventions for weight loss, the resident continued to decline, ultimately leading to multi-organ failure and death shortly after hospital admission.
A resident in an LTC facility complained of pain during peri care but was not assessed or sent to the hospital until over 18 hours later, resulting in a delayed diagnosis of a hip fracture. The resident, with a history of cognitive and physical impairments, was not properly evaluated by the nursing staff, leading to a significant delay in medical treatment.
A resident with multiple health issues experienced a delay in receiving medical attention after complaining of leg pain. Despite an X-ray revealing a fracture, the results were not promptly communicated to the medical team, leading to an 18-hour delay before the resident was sent to the hospital. Miscommunication and misinterpretation of the X-ray report contributed to the delay.
The facility failed to store and serve food under sanitary conditions, with staff not following proper sanitation and food handling practices. Observations revealed staff without hairnets, handling food and sanitized silverware with bare hands, and incomplete dishwasher logs. Additionally, the ice machine used for residents was found dirty, with no cleaning log maintained.
The facility failed to ensure that a CNA was appropriately certified to practice in the State of Texas, resulting in the CNA working many hours with an expired license. Miscommunication regarding the State's licensing extension policy contributed to this oversight.
The facility failed to document and administer wound care orders for a resident with multiple stage 3 pressure injuries. Despite physician's orders, the treatments were not properly entered into the electronic health record, leading to inadequate care. Interviews revealed that the Wound Care Nurse was behind on documentation, and the Director of Nursing acknowledged the importance of timely documentation to prevent delays in treatment.
A facility failed to develop and implement a comprehensive care plan for a resident receiving hospice care services. Despite the resident's multiple medical conditions and the requirement to include hospice care in the care plan, this was not done, leading to potential confusion among staff about the resident's care needs.
The facility failed to develop and implement a comprehensive person-centered care plan for a resident within 21 days of admission. The care plan, initiated 40 days after admission, was not signed by any entity, placing the resident at risk for unmet medical, physical, and psychosocial needs. Interviews revealed the delay was due to the MDS Nurse's workload and oversight.
A facility failed to provide proper incontinent care for a resident, as CNA did not separate the labia and wiped from back to front, risking contamination and infection. The resident, with multiple diagnoses and requiring extensive ADL assistance, was not cleaned according to facility policy, despite recent staff training.
The facility had a medication error rate of 10%, involving two residents. One resident received the wrong allergy medication, and another did not receive prescribed Vitamin D due to unavailability and was given an incorrect multivitamin. Both errors were due to staff not following physician orders and facility policies.
The facility failed to ensure proper storage and administration of medications for two residents. One resident was self-administering Salonpas patches without authorization, and another had Nystatin powder applied by CNAs, contrary to facility policy requiring licensed nurses to administer prescribed topical medications.
Medications Left at Bedside for Two Residents
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and accessible only to authorized personnel when medications were left at the bedside for two residents. Resident #47, a female with moderate dementia, severe cognitive impairment, impaired safety awareness, and a secure-unit placement for elopement risk, had an order for calcium carbonate chewable tablets. During an observation in her room, a broken tablet in a medication cup was found sitting on her bedside table while she was lying in bed with her eyes closed. During the observation, an LVN stated the resident had Tums that she saved and would not take when initially administered, and staff should not leave medication at the bedside. The LVN then entered the room and administered the medication. In a later interview, the LVN said she thought the resident had consumed all of her morning medication and did not know the Tums had been left. The DON stated residents on the secure unit did not self-administer medications and nursing staff were responsible for watching residents consume medications and ensuring none were left at the bedside. Resident #38, a male with Parkinson's disease, lack of coordination, type II diabetes, contracture of muscle, muscle weakness, and severe cognitive impairment, was observed with Systane lubricant eye drops on his bedside table. He stated he administered the eye drops himself and said his eye doctor had told him it was acceptable, but the facility had not told him he could keep or use the drops. RN staff stated they were unaware of the eye drops in the room and that medications were expected to be secured after administration; one RN also stated Resident #38 did not have a physician order to administer medication. The facility policy stated medications and biologicals were to be stored safely and securely and accessible only to licensed nursing personnel, pharmacy personnel, or staff authorized to administer medications.
Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA A did not perform hand hygiene with glove changes during incontinent care for one resident. The resident had diagnoses including diabetes, immunodeficiency, vitamin deficiency, hyperlipidemia, dementia, schizophrenia, and extrapyramidal and movement disorders. The quarterly MDS indicated a BIMS score of 7 out of 15, severe cognitive impairment, and that the resident required supervision with toileting hygiene, personal hygiene, toilet transfers, and sit-to-stand positions, with frequent bowel and urine incontinence. During observation, the resident was wet with urine and had an odor of urine. CNA A brought supplies into the room and provided incontinent care, including removing soiled clothing and cleaning the groin, penis, buttocks, and anal area with disposable wipes. CNA A then touched the clean brief and fastened it onto the resident without changing gloves or performing hand hygiene, and also touched clean shorts and assisted the resident in dressing before removing the used gloves. CNA A stated she would usually use hand sanitizer but did not have it with her. The DON stated staff were expected to perform hand hygiene before entering the room, between changing gloves, and before exiting the room, and the DON and Administrator stated gloves should be changed when moving from clean to dirty areas and after care before touching clean items. The facility policy stated hand hygiene should be performed before and after applying or removing gloves, before and after providing care, and after contact with bodily fluids such as urine.
Failure to Provide Ordered Wound Care and Sepsis Monitoring
Penalty
Summary
The facility failed to provide wound treatment according to the NP orders for a resident with a worsening sacral pressure ulcer. The resident had diagnoses including peripheral vascular disease, Alzheimer’s disease, muscle weakness, and dependence for personal care. She was cognitively severely impaired, incontinent of bowel and urine, and at high risk for pressure injury based on a Braden score of 12. A new open area to the coccyx was noted, and the wound was initially assessed as a stage 3 sacral wound measuring 4.7 cm by 2.3 cm by 0.2 cm with epithelial tissue, granulation tissue, and slough. The wound worsened over the next week and measured 7.5 cm by 5.2 cm by 0.2 cm, with 90% slough and peri-wound edema, erythema, and induration. The NP documented that the sacral wound was not improved, had increased in size, and cellulitis was present, and the treatment was changed to include Dakins cleanse and Bactrim DS. The order summary also included instructions to clean the wound with NS, apply Santyl, calcium alginate, and dry dressing daily, along with monitoring for signs and symptoms of sepsis and completing a Sepsis UDA assessment if indicated. Record review showed the wound treatment was not documented as administered prior to the start dates, and there was no documentation of treatment on one date when the order fields were blank. The report also states there were no Sepsis UDA assessments completed despite abnormal vital signs, including fever and tachycardia. The resident developed fever, elevated pulse, tremors, and a drop in blood pressure, was sent to the hospital, and was diagnosed with severe sepsis with septic shock. Hospital records described a sacral pressure wound with gas and fluid collection extending into surrounding tissues, and surgery found a stage 4 sacral ulcer with eschar, necrotic fascia, foul-smelling gray discharge, gas gangrene, and myositis.
Failure to Care Plan a Resident's Stage 3 Sacral Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident with a stage 3 sacral wound. Record review showed the resident had diagnoses including peripheral vascular disease, Alzheimer's disease, muscle weakness, and need for assistance with personal care, and she was dependent on staff for toileting hygiene and always incontinent of bowel and urine. A change in condition evaluation documented a new open area to the coccyx, and later orders were entered for treatment of a stage 3 sacral wound with cleansing, Santyl, calcium alginate, and a dry dressing. However, the resident's revised care plan addressed general skin breakdown risk and antibiotics, but did not include the sacral wound or any wound-specific interventions. Interviews with the WCN, ADCO, and DCO showed that wound care planning was expected to be handled by the MDS nurse, WCN, or both, and that wound interventions should be care planned immediately so staff would know the plan of care. The DCO stated the wound care planning was missed during weekly standards of care meetings, and the wound was not listed on the care plan. The facility's comprehensive care plan policy stated that every resident would have an individualized interdisciplinary plan of care that is revised as the resident's condition changes and includes physician orders and skin prevention.
Abuse and Physical Force Toward Residents
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect when multiple staff members were observed using physical force and vulgar language toward residents on the secured memory care unit. Resident #1 had severe cognitive impairment with a BIMS score of 1 and diagnoses including dementia and memory deficit. Video footage showed a CNA repeatedly telling the resident to sit down and then forcefully pushing her down into a couch as she attempted to stand, causing her to cry. The same CNA was also observed later slapping Resident #2 on the right arm, grabbing his left arm, and forcefully pulling him into a standing position while he appeared confused and unsteady. Resident #4 had diagnoses including epilepsy, Parkinson's disease, cognitive impairment, seizures, anxiety disorder, and autistic disorder, and his care plan noted that he did not like to be physically touched by others. Video footage showed a CNA using vulgar language toward him, grabbing him by the shoulders, and forcefully walking him down the hallway to his room while he appeared to cry. Resident #8 had severe cognitive impairment with diagnoses including dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder. Video footage showed the same CNA grabbing her by the shoulders and forcing her to walk out of the activities room while using offensive language toward her. Resident #10 had severe cognitive impairment and diagnoses including dementia with psychotic and mood disturbance, delusional disorders, bipolar disorder with psychotic features, and anxiety. During a physical altercation with a laundry aide, the resident grabbed the aide's hair and the aide struck the resident in the face. The facility's investigation records and witness statements described the resident as being in a psychotic episode and confirmed that the aide struck the resident during the altercation. The report also states that the facility identified these incidents through camera review and investigation, and that the non-compliance was cited as past non-compliance with an Immediate Jeopardy period beginning on 05/20/2026 and ending on 05/21/2026.
Missed Clonazepam Doses Led to Seizure Episode
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with a history of seizures, epilepsy, anxiety, Parkinson’s disease, mild cognitive impairment, and autistic disorder. The resident had an active order for Clonazepam 2 mg via PEG tube twice daily for anti-seizure use, and the care plan directed staff to administer the medication as ordered and monitor for side effects and effectiveness each shift. Record review showed that four scheduled doses of Clonazepam were not administered because the medication was unavailable in the facility. The MAR documented the missed doses with a code for other/see progress notes, and nursing notes reflected that the medication was on order or not available. Staff interviews indicated the medication was missing from the cart and medication room, and there was discussion about reordering, contacting the pharmacy, and using the emergency kit, but the medication was not available when needed. After the missed doses, the resident experienced three back-to-back seizure episodes with no return to baseline between episodes and was sent to the hospital for evaluation and treatment. Hospital records documented that the resident arrived from the facility after reported seizure activity, and the ED note stated the presentation was most consistent with breakthrough seizures in a patient without a dedicated antiepileptic regimen aside from scheduled clonazepam. Facility staff and the DON gave differing accounts about the indication for clonazepam and when the refill was requested, while the pharmacy stated the prescription was received and sent to the facility on 5/11/26.
Unsecured Medication Cart and Unattended Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in locked compartments, as required by professional standards. During an observation, a lidocaine patch and two unidentifiable pills were found left unattended on top of an unlocked medication cart in a hallway accessible to residents. The medication cart was not under the direct observation of authorized staff at the time. Interviews with nursing staff and administration confirmed that the expectation is for medication carts to be locked and for medications not to be left unattended. Staff acknowledged the risk of residents accessing unsecured medications and described the proper procedures for medication administration and cart security. Despite these expectations, the incident occurred when a registered nurse left the cart unlocked and medications unattended while assisting another staff member. Other staff interviewed stated they would secure the cart and report any lapses if observed. The facility was unable to provide its Medication Storage/Labeling policy when requested. No medications were reported taken by residents, but the potential for harm existed due to the unsecured medications and unlocked cart.
Failure to Prevent Elopement Despite Wander Guard and Supervision Protocols
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, cognitive impairment, and exit-seeking behaviors was able to leave the facility unattended despite being identified as an elopement risk and having a wander guard device in place. The resident, who was a new admission and had not adjusted to the facility, was independently ambulatory and had a care plan that included interventions for wandering and elopement risk. On the day of the incident, the resident exited the building and was found at a neighboring business approximately 20 minutes later. The wander guard device was in place at the time of the incident, and the resident was last seen in the facility about 20 minutes before being located outside. Staff interviews revealed gaps in supervision and monitoring, particularly during times when the receptionist was not present at the front desk. Some staff were not fully aware of the elopement protocols or the specific residents at risk, and there was confusion regarding the operation of the wander guard system, especially when doors were already open. The receptionist and other staff members could not recall seeing the resident leave, and there was uncertainty about who was responsible for monitoring the doors at the time of the incident. Additionally, some staff were unclear about the functionality of the wander guard system and their roles in preventing elopement. Observations and interviews indicated that while the facility had security measures such as magnetic locks, coded entry, and wander guard alarms, these systems did not prevent the resident from leaving the premises. The alarm system was tested and found to be functional, but it was not clear how the resident was able to exit without staff intervention. The lack of consistent supervision, unclear staff responsibilities, and insufficient training contributed to the failure to prevent the resident's elopement.
Failure to Notify Physician of Resident's Significant Health Decline
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. This deficiency was identified for a resident who experienced a decline in health, including weight loss, physical decline in performing activities of daily living (ADLs), and a burning sensation in the throat. Despite these changes, the facility did not notify the resident's physician or family member, which could have led to inadequate medical interventions and a decline in the resident's health. The resident, a 66-year-old male, was admitted with multiple health issues, including chronic obstructive pulmonary disease, protein-calorie malnutrition, and dysphagia. The resident was on a mechanically altered diet and had a history of weight loss. Despite interventions such as dietary supplements and appetite stimulants, the resident continued to lose weight. The facility's records did not show any physician notes or notifications regarding the resident's change in condition, indicating a lack of communication with the physician. Interviews with facility staff revealed that the Director of Nursing (DON) and other staff members were aware of the resident's condition and weight loss but did not contact the physician. The facility relied on a nurse practitioner (NP) for resident care, and the physician was not actively involved. The resident's responsible party expressed concerns about the lack of communication and the resident's weight loss, which was not addressed until shortly before the resident's passing.
Neglect of Resident Leading to Severe Health Decline
Penalty
Summary
The facility failed to provide adequate care and assistance for a resident who was unable to perform activities of daily living, leading to neglect. The resident, a 66-year-old male with multiple medical conditions including chronic obstructive pulmonary disease (COPD), protein-calorie malnutrition, and cognitive communication deficit, was found in a severely neglected state when transferred to a local hospital. Upon arrival at the hospital, the resident was covered in fresh and dried feces and urine, indicating a lack of personal hygiene care at the facility. The resident's medical records revealed a significant weight loss over several months, with interventions such as dietary supplements and regular monitoring of food intake documented but seemingly ineffective. Despite being on a mechanically altered diet and receiving nutritional supplements, the resident continued to lose weight, dropping to 64 pounds from an initial weight of 85 pounds at admission. The resident's care plan required substantial assistance for daily activities, including toileting and personal hygiene, which were not adequately provided, as evidenced by the resident's condition upon hospital admission. The hospital records indicated that the resident was in a critical state upon arrival, with severe cachexia, labored breathing, and suspected neglect. The resident was found to be severely malnourished and in pain, requiring immediate medical intervention, including increased oxygen support and emergency transport. The lack of adequate care and monitoring at the facility contributed to the resident's rapid health decline, ultimately leading to multi-organ failure and septic shock, resulting in the resident's death shortly after hospital admission.
Failure to Provide Timely Assessment and Care for Resident's Pain
Penalty
Summary
The facility staff failed to provide appropriate treatment and care according to professional standards of practice, the comprehensive care plan, and the resident's choices for one resident reviewed for quality of care. The deficiency involved a resident who complained of pain during peri care but was not assessed or sent to the hospital until over 18 hours later. The resident was eventually diagnosed with an intertrochanteric fracture of the right femoral neck. The resident, who had a history of cognitive communication deficit, contracture of muscle, hemiplegia, and other conditions, was bed-bound and required assistance with activities of daily living. On the morning of the incident, a CNA reported the resident's complaint of pain to an LVN, who offered pain medication that the resident refused. However, the LVN did not conduct a pain assessment or further evaluate the resident's condition, as the resident was not exhibiting visible signs of pain. The facility's failure to promptly assess and address the resident's pain led to a delay in medical treatment. The resident's X-ray, which revealed the fracture, was not communicated effectively to the necessary medical personnel, resulting in a significant delay in the resident being sent to the hospital. This oversight placed the resident at risk of further injury and pain.
Delayed Notification of Diagnostic Results Leads to Resident Harm
Penalty
Summary
The facility failed to promptly notify the ordering physician or nurse practitioner of diagnostic results that fell outside of clinical reference ranges, as required by their policies and procedures. This deficiency was identified in the case of a resident who complained of pain during peri care at 5:00 am on June 6, 2024, but was not sent to the hospital until over 18 hours later. Upon hospital admission, the resident was diagnosed with an intertrochanteric fracture of the right femoral neck of indeterminate age. The resident, an elderly female with a history of cognitive communication deficit, muscle contracture, aneurysm, constipation, hemiplegia, hemiparesis, and insomnia, was bed-bound and required assistance with activities of daily living (ADLs). On June 6, 2024, the Assistant Director of Nursing (ADON) was informed by a Certified Occupational Therapy Assistant (COTA) that the resident was experiencing pain in her right leg. The ADON conducted a brief assessment and reported the issue to the Director of Nursing (DON), who ordered an X-ray. The X-ray was performed, and the results, which indicated a fracture, were available by 2:25 pm the same day. Despite the availability of the X-ray results, there was a delay in notifying the appropriate medical personnel. The Licensed Vocational Nurse (LVN) misinterpreted the X-ray report and sent it to the nurse practitioner via text message, but the nurse practitioner did not receive it. The DON eventually reviewed the X-ray report at 11:00 pm and instructed another LVN to contact the on-call doctor to arrange for the resident's transfer to the hospital. The resident was finally sent to the hospital at 12:02 am on June 7, 2024, highlighting a significant delay in addressing the resident's medical needs.
Failure to Maintain Sanitary Conditions in Food Service
Penalty
Summary
The facility failed to store and serve food under sanitary conditions per professional standards for food service safety. Observations revealed multiple instances where staff did not follow proper sanitation and food handling practices. Staff members were seen in the kitchen without hairnets, and one staff member was observed transporting food trays without a beard net. Additionally, staff members were observed handling food and sanitized silverware with bare hands, which could lead to cross-contamination. The facility's dishwasher logs were incomplete, and staff did not measure water temperature and PPM as required before and during the sanitizing process. Instead, they measured it after sanitizing, contrary to the facility's policy and training. The logs for several days were missing, and the DFS admitted to filling in the missing information without knowing the actual measurements. This practice could compromise the effectiveness of the sanitization process and increase the risk of foodborne illnesses among residents. Furthermore, the ice machine used to distribute ice to residents was found to be dirty, with white and yellowish stains, and there was no cleaning log maintained for it. Staff members admitted to not verifying the cleanliness of the machine before use, and the housekeeper responsible for cleaning it had only started working at the facility recently. The facility's failure to maintain proper sanitation and food handling practices could put all 65 residents who received meals from the facility kitchen at risk of foodborne illnesses.
Failure to Ensure CNA Certification
Penalty
Summary
The facility failed to ensure that CNA O was appropriately certified to practice and provide CNA care in the State of Texas. Despite CNA O's belief that her license was current, it was discovered that her license had expired. CNA O had worked many hours at the facility since the expiration of her license. The facility's corporate HR department did not have CNA O on the list of expired licenses, and there was a misunderstanding regarding the State's CNA license extension policy. The extension granted by the State did not apply to CNA O as her license had expired before the extension period began. This resulted in CNA O working without a valid license for an extended period, which was confirmed through interviews and record reviews, including timecard statements and the State's license verification website. The facility's administration and corporate HR designee acknowledged the oversight and the miscommunication regarding the State's licensing extension. The facility's records showed that CNA O had worked a significant number of hours while her license was expired. The facility's undated staff roster and EMR review also confirmed that CNA O was listed as an active Resident Care Provider despite her expired license. This failure to ensure proper certification could place residents at risk of receiving care from staff who were not properly trained and certified.
Failure to Document and Administer Wound Care Orders
Penalty
Summary
The facility failed to ensure clinical records were maintained in accordance with accepted professional standards and practices for Resident #37. Specifically, the facility did not input treatment orders and document the administration of those orders into the electronic health record for Resident #37's stage 3 pressure injuries. This failure was observed in the treatment of pressure injuries on the right ischium, right posterior thigh, and left posterior thigh, which were not properly documented or administered as per the physician's orders. Resident #37, a [AGE] year-old female with diagnoses including type 2 diabetes, end-stage renal disease, morbid obesity, bipolar disorder, and heart failure, was admitted to the facility with multiple pressure injuries. Despite the physician's orders for specific wound care treatments, the facility's records showed no active wound orders for the stage 3 pressure injuries on the right posterior thigh and left posterior thigh. Additionally, the treatment for the stage 3 pressure injury to the right ischium was inconsistently documented, with discrepancies in the order creation and discontinuation dates. Interviews with the Wound Care Nurse (WCN) and the Director of Nursing (DON) revealed that the wound orders were not entered into the system in a timely manner, leading to a lack of proper documentation and administration of the treatments. The WCN admitted to being behind on documentation, which resulted in the orders not being entered or administered as required. The DON acknowledged the importance of timely documentation and indicated that failure to do so could delay treatment and worsen the resident's condition.
Failure to Include Hospice Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving hospice care services. The resident, who had multiple medical conditions including senile degeneration of the brain, generalized anxiety disorder, hypertension, GERD, pressure ulcers, contractures, muscle wasting, lack of coordination, amputation of the left leg below the knee, colostomy status, and type 2 diabetes mellitus, was admitted to the facility and was receiving hospice care services. Despite this, the resident's care plan did not include any focus on the hospice care services he was receiving, which is a requirement for ensuring that all medical, nursing, and psychosocial needs are met in a timely manner. This omission was confirmed through interviews with the resident, the Wound Care Nurse (WCN), the Director of Nursing (DON), and the MDS Nurse, all of whom acknowledged that the care plan should have included hospice care services but did not. The MDS Nurse admitted that the oversight might have been due to the high number of admissions at the time. The DON also stated that while the care plan is essential for guiding staff on how to care for a resident, the nurses would still know to follow the physician's orders in the EHR. However, the lack of documentation in the care plan could lead to confusion among staff about the resident's care needs and who to contact for hospice care services. The facility's Comprehensive Care Plan policy mandates that every resident should have an individualized interdisciplinary plan of care, which should be updated with any new information as needed. The failure to include hospice care services in the resident's care plan is a clear violation of this policy and places the resident at risk of not receiving the required medical and end-of-life care in a timely manner.
Failure to Timely Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for one of twelve residents reviewed for care plans. Specifically, the facility did not develop and implement a comprehensive person-centered care plan to address the needs of a resident within 21 days of admission. The care plan for this resident, initiated 40 days after admission, was not signed by any entity, the resident, or his representative. This failure placed the resident at risk for not receiving care and services to meet his medical, physical, and psychosocial needs. The resident in question was a male with multiple diagnoses, including secondary hypertension, Type 2 diabetes mellitus, atherosclerotic heart disease, hyperlipidemia, chronic kidney disease, chronic obstructive pulmonary disease, mood disorder, unspecified dementia, psychotic disturbance, anxiety, cerebral infarction, muscle weakness, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, frontotemporal neurocognitive disorder, and muscle wasting and atrophy. Interviews with the MDS Nurse and the DON revealed that the care plan was not completed on time due to the MDS Nurse's workload and oversight. The facility's policy required the comprehensive care plan to be developed within 21 days of admission and updated as needed, which was not adhered to in this case.
Improper Incontinent Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to ensure that a resident who is incontinent of urine received appropriate treatment and services to prevent urinary tract infections. Specifically, during an observation, CNA CC did not separate the resident's labia and wiped from back to front during incontinent care. This improper technique was confirmed by CNA N, who assisted during the care and noted that the correct procedure was not followed. Both CNAs had recently received in-service training and skills check-offs on incontinent care, but the proper technique was not applied during the observed care session. The resident involved, a female with diagnoses including hypertension, neuropathy, and heart failure, required extensive assistance with all activities of daily living (ADLs) due to moderately impaired cognition. Interviews with CNA CC, CNA N, RN A, and the Director of Nursing (DON) confirmed that the improper cleaning technique could lead to contamination and infection. The facility's policy on perineal care, which mandates cleaning from front to back and separating the labia, was not adhered to during the incident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in a medication error rate of 10%. This was based on three errors out of 28 opportunities, involving two residents. One resident, a male with moderate cognitive impairment and multiple diagnoses including hemiplegia and type 2 diabetes, was administered Cetirizine instead of the prescribed Loratadine by MA I. The medication aide mistakenly believed the two medications were the same and did not verify the correct medication with the nurse, despite having Loratadine available on the medication cart. The Director of Nursing (DON) and the Administrator confirmed that the medication aide should have followed the physician's orders precisely. Another resident, a female with severe cognitive impairment and diagnoses including vitamin D deficiency and congestive heart failure, did not receive her prescribed Vitamin D 50,000 units. MA JJ documented that the medication was not administered due to vitals being outside of parameters, although the actual reason was the unavailability of the medication from the pharmacy. Additionally, MA JJ administered a multivitamin with minerals instead of the prescribed multiple vitamin without minerals. The DON confirmed that the correct medication was available on the cart and should have been administered as per the physician's order. The facility's Oral Medication Administration policy requires staff to review and confirm medication orders on the MAR before administering medications. Both medication aides failed to adhere to this policy, leading to the medication errors. The DON and the Administrator emphasized the importance of following physician orders and ensuring medication availability to prevent such errors. The deficiencies observed could place residents at risk of inadequate therapeutic outcomes and other health complications.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and accessed only by authorized personnel for two residents. Resident #64 had two boxes of Salonpas patches at her bedside without a medical order to self-administer. Despite having severe cognitive impairment, she was applying the patches herself, which were meant to be applied by the medication aide. The medication aide and LPN were unaware of the correct application instructions and the resident's unauthorized self-administration, leading to improper medication management and potential health risks for the resident. Resident #21 had a prescription box of Nystatin powder on her TV stand, which was being applied by CNAs during brief changes. The CNAs were not authorized to administer prescribed topical medications, and the LPN and DON confirmed that only licensed nurses should apply such medications. The CNAs were applying the Nystatin powder based on the resident's instructions, without proper oversight from licensed nursing staff, leading to a breach in medication administration protocols. Interviews with the DON and Administrator revealed that the facility's policy required a self-administration assessment for residents to self-administer medications, which was not conducted for either resident. The facility's failure to adhere to medication storage and administration protocols placed residents at risk of inadequate therapeutic outcomes and potential health decline.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 573 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Humble
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakmont Healthcare And Rehabilitation Of Humble | 1 mi | ★★★★★ | 10 | 0 |
| Park Manor Of Humble | 1.1 mi | ★★★★★ | 9 | 0 |
| Crimson Heights Health & Wellness | 1.2 mi | ★★★★★ | 4 | 0 |
| Deerbrook Skilled Nursing And Rehab Center | 1.7 mi | ★★★★★ | 20 | 3 |
| Fall Creek Rehabilitation And Healthcare Center | 4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Focused Care At Humble.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.