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 Westwood during CMS and state inspections, most recent first.
A resident with a suprapubic Foley catheter did not receive appropriate care when staff failed to keep the catheter drainage bag below the bladder during wound care, contrary to physician orders and facility policy. Both the LVN and CNA involved acknowledged awareness of the correct procedure but did not follow it during the observed care episode.
A deficiency was identified when an LVN failed to don required PPE while providing pressure ulcer treatment to a resident on enhanced barrier precautions. The resident, who was dependent on staff for all ADLs and had multiple medical conditions including a suprapubic Foley catheter, received wound care without the LVN wearing gown and gloves, despite clear signage and facility policy requiring such precautions.
The facility's kitchen staff improperly stored personal items in the walk-in cooler and placed dish crates on the wet floor, violating infection control standards. The Dietary Manager and Administrator acknowledged these actions as cross-contamination risks, despite staff training on proper procedures.
The facility failed to ensure safe storage of residents' food items in a refrigerator, with undated and unlabeled perishable items observed. The ADON identified some items as belonging to residents, while others were possibly stored by staff. The facility's policy requires labeling and dating of food brought by family, but this was not adhered to, risking cross-contamination.
A facility failed to include a resident's Dementia and Hypertension diagnoses and related medications in their care plan. The resident, with severe cognitive impairment and dependent on staff for all ADLs, had active orders for hypertension medications that were omitted from the care plan. Staff interviews confirmed the oversight, which should have triggered a Care Area Assessment according to facility policy.
A resident with severe cognitive impairment and multiple medical conditions was not repositioned every two hours as required, leading to the development of a pressure ulcer. Observations showed the resident consistently lying flat on her back without repositioning aids, contrary to care plan directives. Staff interviews revealed a lack of adherence to repositioning protocols, and the Wound Care Nurse was unaware of the resident's skin condition until it was pointed out.
A resident with severe cognitive impairment and an indwelling catheter was at risk of infection due to improper Foley catheter care. During wound care, a CNA placed the catheter bag on the bed at the same level as the bladder, against facility policy and training. This action could lead to urine backflow and infection, as acknowledged by the staff involved.
The facility failed to ensure proper administration of enteral feeding and medication for residents with feeding tubes. An RN pushed water and medications through g-tubes instead of using gravity, risking complications. Additionally, an LVN did not check a feeding bag for dates, risking infection or abdominal issues. These actions were contrary to facility policy and physician orders.
A resident with severe cognitive impairment and multiple medical conditions did not receive appropriate pain management during incontinent care. Despite showing signs of pain, the CNA continued care without notifying the Wound Care Nurse promptly. The Wound Care Nurse also failed to assess the resident's pain level during a skin assessment. The DON confirmed that care should have been stopped when the resident was in pain.
A resident with a complex medical history experienced unmanaged pain during incontinent care due to the failure of a CNA and a Wound Care Nurse to stop care and assess pain levels. Despite the resident's grimacing and verbal expressions of pain, the CNA did not notify the nurse promptly, and the nurse did not adequately assess or address the pain, relying on existing orders without further intervention.
A facility failed to maintain an effective infection control program, as a CNA and a Wound Care Nurse did not follow proper hand hygiene and cleaning procedures during care for a resident with an indwelling Foley catheter. The resident, who had multiple medical conditions and was dependent on staff for care, was not properly cleaned, and the catheter was not secured, increasing the risk of infections. Staff interviews confirmed lapses in adherence to facility policies.
A resident with multiple health conditions and moderate cognitive impairment was found to have a bedside drinking cup with black residue resembling mold or dirt, which was discovered by a family member and reported to staff. The nurse on duty confirmed the residue and replaced the cup, while other staff interviews indicated that the evening shift was responsible for ensuring cups were clean and replaced nightly. Facility policies and in-service training required proper cleaning and handling of hydration cups, but there was no documentation of the facility addressing the incident at the time.
The facility did not maintain a functional door alarm system, allowing several residents with cognitive impairments and wander guard devices to exit the building without staff being alerted. Staff interviews and documentation confirmed that the alarm system was unreliable for about a month, and residents were able to leave unsupervised, sometimes not being noticed missing until later. Manual monitoring of the door was not consistently implemented when the alarm was down, resulting in residents with dementia, Alzheimer's, and other impairments being exposed to accident hazards.
A deficiency was identified in a facility's failure to submit Nursing Facility Specialized Services (NFSS) forms timely, affecting five residents who required PASRR services. Due to staff changes and the resignation of the previous Rehabilitation Director, the NFSS forms were not submitted within the required timeframe, delaying access to specialized services such as OT, PT, ST, and DME. Residents with various diagnoses, including dementia and cerebral palsy, did not receive recommended therapies, highlighting a significant lapse in care coordination.
Failure to Maintain Proper Catheter Positioning During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate care for a resident with a suprapubic Foley catheter. During wound care, the resident's catheter drainage bag was placed on the bed rather than being hung below the level of the bladder, as required by physician orders and facility policy. This was observed while the resident, who was totally dependent on staff for all activities of daily living due to severe cognitive impairment and multiple comorbidities, was being transferred and treated for pressure ulcers. The catheter bag contained urine and was not properly positioned throughout the procedure. Interviews with the LVN and CNA involved revealed that both staff members were aware of the requirement to keep the catheter bag below the bladder to prevent backflow of urine, but failed to do so during the care episode. The facility's policy and the resident's care plan both specified the need for proper catheter positioning to prevent complications. The incident was confirmed through observation, staff interviews, and review of the resident's medical records and care plan.
Failure to Use Required PPE During Pressure Ulcer Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use the required personal protective equipment (PPE) while performing pressure ulcer treatment on a resident who was on enhanced barrier precautions. The resident had multiple medical conditions, including neuromuscular dysfunction of the bladder, constipation, orthostatic hypotension, a bacterial infection, cognitive communication deficit, and required assistance with all activities of daily living. The resident also had a suprapubic Foley catheter and was dependent on staff for care. The care plan indicated the need for staff to anticipate and meet all care needs, including maintaining cleanliness and comfort. On the day of the incident, the LVN entered the resident's room, which had signage indicating enhanced barrier precautions, and performed wound care without donning gown and gloves as required. The LVN later acknowledged forgetting to use PPE and recognized the importance of PPE in preventing infection. Facility policy and CDC guidelines both require the use of gown and gloves for high-contact care activities with residents on enhanced barrier precautions, particularly those with open wounds or indwelling medical devices. The facility's Director of Nursing confirmed that staff are trained on these precautions and that appropriate signage was posted in the resident's room.
Improper Storage and Handling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their only kitchen, as observed during a survey. Staff members stored personal items, including energy drinks, a liquid creamer, and a lunch bag with water bottles, on the second shelf of the walk-in cooler, which is designated for facility use only. This practice was acknowledged by the Dietary Manager (DM) as a cross-contamination risk, despite staff having received training on infection control and storage protocols. Additionally, three gray dish crates were improperly placed on the wet floor near the dishwasher and three-compartment sink. These crates were later moved to a clean surface, which the DM and Dishwasher A recognized as a violation of infection control practices due to the potential for cross-contamination. The Administrator confirmed that kitchen equipment should not be placed on the floor and that personal items should not be stored in the walk-in cooler, as these actions could lead to cross-contamination.
Deficiency in Safe Storage of Residents' Food Items
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents' food items in a refrigerator located on the 400 hall. Observations revealed undated and unlabeled perishable food items, including green vegetables, soup, chicken, supplement shakes, protein drinks, sugar, and oranges. The Assistant Director of Nursing (ADON) identified some items as belonging to residents, while others were possibly stored by nursing staff for medication pass usage. The ADON acknowledged that the nursing staff were responsible for monitoring the refrigerator and ensuring proper labeling and dating of food items. The facility's policy on food from outside sources requires that food brought in by family members be labeled with the resident's name, receive date, and open date. The Administrator stated that family members should inform the nursing staff when bringing food, and the staff would then date the food with the start date, discard date, and resident information. However, the observations indicated a lack of adherence to this policy, as several items in the refrigerator were not labeled or dated, potentially placing residents at risk for cross-contamination and other air-borne illnesses.
Failure to Address Diagnoses and Medications in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not address the resident's diagnoses of Dementia and Hypertension, nor the medications prescribed for these conditions. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had active orders for hypertension medications that were not included in the care plan. This oversight was identified during a review of the resident's records, which showed that the care plan lacked focus areas for the resident's medical conditions and prescribed treatments. Interviews with facility staff, including the MDS nurse and the Director of Nursing, revealed that the care plan should have included the resident's diagnoses and medications. The MDS nurse acknowledged the omission and stated that these should have automatically triggered a Care Area Assessment. The facility's policy requires comprehensive care plans to be developed within 21 days of admission and revised quarterly or as the resident's condition changes, but this was not adhered to in this case.
Failure to Reposition Resident Leads to Pressure Ulcer Development
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention care for a resident, identified as Resident #49, who was at risk for developing pressure ulcers. The resident, a female with multiple medical conditions including severe cognitive impairment, was not repositioned every two hours as per physician orders and care plan directives. Observations on multiple occasions over two days revealed that the resident was consistently left lying flat on her back without the use of additional pillows or wedges for repositioning, which are essential for pressure ulcer prevention. The resident's medical history included conditions such as traumatic brain injury, Type 2 Diabetes Mellitus, and dementia, which contributed to her being dependent on staff for all activities of daily living. Despite the care plan indicating the need for frequent repositioning, the resident was observed in the same position for extended periods, and staff interviews confirmed a lack of adherence to repositioning protocols. The resident's skin assessment progress notes indicated the development of an open area between the sacral and coccyx region, which was not previously documented. Interviews with the Wound Care Nurse and the Director of Nursing (DON) highlighted a lack of awareness and communication regarding the resident's skin condition. The Wound Care Nurse was unaware of the open area until it was pointed out during an observation, and there was no specific policy provided for repositioning residents to prevent pressure ulcers. This deficiency in care placed the resident at risk for worsening skin conditions and potential complications.
Improper Foley Catheter Care Poses Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a potential risk of urinary tract infections. During a wound care session, a Certified Nursing Assistant (CNA) placed the resident's Foley catheter bag on the bed at the same level as the resident's bladder, contrary to the facility's policy and training, which requires the catheter bag to be positioned below the bladder to prevent urine backflow. This improper placement was observed during a wound care treatment session, and both the Wound care nurse and CNA acknowledged the risk of infection due to urine backflow. The resident involved was an elderly female with severe cognitive impairment, dependent on staff for all activities of daily living, and had multiple medical conditions, including neurogenic bladder and pressure ulcers. The facility's policy and the resident's care plan clearly stated that the catheter bag should be secured below the bladder level. Despite having received training on Foley catheter care, the staff involved did not adhere to these guidelines, as confirmed by interviews with the Wound care nurse, CNA, and the Director of Nursing (DON).
Improper Administration of Enteral Feeding and Medication
Penalty
Summary
The facility failed to ensure that residents with feeding tubes received appropriate treatment and services to prevent complications. Specifically, RN A did not administer medications and water by gravity for Residents #32 and #49, instead pushing the water through the g-tube, which could lead to complications such as stoma problems, pressure, or bleeding. This was observed during medication administration, where RN A used a syringe to push water and medications through the g-tube, contrary to the facility's policy and physician orders. Additionally, LVN A did not check Resident #37's feeding bag for dates during her shift, which is a critical step to ensure the feeding is not expired and is safe for the resident. The absence of a label on the feeding bag was noted during an observation, and LVN A admitted to not noticing the missing label. This oversight could lead to the risk of infection or abdominal issues if the feeding was sour. The facility's policy on enteral tube medication administration requires that medications be administered using gravity flow, with each medication given separately and the tube flushed between medications. The failure to adhere to these guidelines and physician orders for the residents involved could result in significant health risks, including aspiration pneumonia and other complications associated with improper enteral feeding management.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #49, who required such services. During an observation of incontinent care, CNA H continued to perform care despite the resident expressing pain through grimacing and verbalizing 'ouch.' CNA H did not notify the Wound Care Nurse of the resident's pain in a timely manner, which is contrary to the in-service training she received about reporting pain to the charge nurse. Resident #49, a [AGE] year-old female with a history of severe cognitive impairment, brain injury, and other medical conditions, was at risk for pressure ulcers and had a care plan that included pain management interventions. Despite this, the resident's pain was not adequately monitored or addressed. The resident's MAR indicated no pain was documented every shift, yet during care, the resident exhibited signs of discomfort, and an open skin area was later identified. The Wound Care Nurse, upon being informed, did not initially assess the resident's pain level during a skin assessment, even though the resident was grimacing and hitting the bed. The nurse later acknowledged the resident's burning sensation but did not provide new pain management interventions, as the physician did not alter the standing order. The DON confirmed that both CNA H and the Wound Care Nurse should have stopped care when the resident was in pain and emphasized the importance of monitoring pain every shift.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the context of pain management. The resident, a female with a complex medical history including brain compression, diabetes, post-traumatic hydrocephalus, dementia, and other conditions, was observed to be in pain during incontinent care. Despite the resident's grimacing and verbal expressions of pain, the CNA continued with the care without notifying the Wound Care Nurse in a timely manner. Further observations revealed that the Wound Care Nurse also failed to adequately assess the resident's pain level during a subsequent skin assessment. Although the resident was grimacing and hitting the bed, indicating discomfort, the nurse did not stop the care to assess the pain level immediately. The nurse later acknowledged the resident's expression of burning pain but did not take immediate action to address it, relying instead on existing standing orders for pain management without further intervention. The Director of Nursing (DON) confirmed that both the CNA and the Wound Care Nurse should have halted care when the resident exhibited signs of pain. The DON also noted that the facility's protocol required monitoring for pain every shift, which was not adhered to in this instance. This oversight in pain management could lead to unmanaged pain for the resident, as indicated by the DON.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and inadequate cleaning procedures during care for a resident. Specifically, a CNA did not wash her hands or use hand sanitizer between glove changes while providing indwelling Foley catheter and incontinent care. Additionally, the CNA did not properly clean the resident's labia or buttocks, which are critical steps in preventing infections. The resident involved was an elderly female with multiple medical conditions, including cognitive impairments, diabetes, and a neuromuscular dysfunction of the bladder requiring an indwelling Foley catheter. The resident was dependent on staff for all activities of daily living and required extensive assistance with incontinent care. Observations revealed that the resident's catheter was not secured with a leg strap, and there was a brownish discharge with a foul odor present, indicating potential infection risks. Interviews with the CNA and the Wound Care Nurse confirmed lapses in hand hygiene and cleaning procedures. Both staff members acknowledged the importance of proper cleaning to prevent infections and skin breakdown but failed to adhere to the facility's policies on perineal care, catheter care, and hand hygiene. The Director of Nursing and Assistant Director of Nursing also recognized the deficiencies and the potential negative outcomes for the resident, such as urinary tract infections and skin breakdown.
Failure to Provide Clean Drinking Cup for Resident
Penalty
Summary
A deficiency occurred when a resident was found to have a drinking cup at bedside with black discoloration resembling mold or dirt at the bottom. The issue was discovered by a family member who, upon visiting, noticed the residue while preparing to pour lemonade for the resident. The family member confirmed with the resident that she had been drinking from the cup and subsequently reported the concern to facility staff. Photographs of the cup were taken and provided as evidence of the unsanitary condition. The resident involved was an elderly female with multiple diagnoses, including anemia, intestinal obstruction, moderate protein-calorie malnutrition, urinary tract infection, and a need for assistance with personal care. Her cognitive status was moderately impaired, as indicated by a BIMS score of 12 out of 15. The resident's care plan included goals for adequate nutrition and fluid intake, and she was identified as being at risk for nutritional impairment. There were no progress notes documenting the facility's response to the cup residue on or around the date of the incident. Interviews with staff revealed that the evening shift was responsible for collecting and replacing resident cups nightly, and that the expectation was for all cups to be clean and free of residue. The nurse on duty at the time recalled being informed of the dirty cup and observed the residue herself, but could not explain its origin. She replaced the cup and checked other residents' cups, finding no similar issues. The Director of Nursing and Administrator were not aware of the incident until after it occurred. Facility policy required clean food storage and handling, and in-service training had addressed the process for swapping and cleaning hydration cups.
Failure to Maintain Functional Door Alarms and Supervision for Elopement Risk Residents
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for five residents identified as being at risk for elopement or requiring wander guard devices. The main entrance door alarm system was malfunctioning, which allowed residents with wander guards to exit the facility without alerting staff. Multiple staff interviews confirmed that the door alarm would sometimes not sound when residents exited, especially if the door was already open, and that the system had been malfunctioning intermittently for about a month. During this period, residents with cognitive impairments and a history of wandering or elopement risk were able to leave the facility unsupervised. One resident with severe cognitive impairment and a history of stroke was able to exit the facility in his wheelchair by following visitors out the main door. Staff did not immediately notice his absence, and he was later found outside the facility by staff members. Documentation and interviews revealed that the resident was wearing a wander guard, but the malfunctioning door alarm did not activate when he exited. Other residents with similar cognitive and physical impairments, including those with Alzheimer's disease, dementia, and a history of exit-seeking behavior, were also identified as being at risk due to the faulty alarm system. In some cases, residents were able to remove their wander guard devices or were not wearing them at the time of exit. Staff interviews indicated that when the wander guard system was not functioning, staff were expected to monitor the door manually, but this was not always consistently implemented. Maintenance staff confirmed the alarm system's unreliability, and nursing staff described incidents where residents exited unnoticed or alarms failed to sound. The lack of a consistently functioning alarm system and insufficient supervision directly contributed to residents with significant cognitive and physical impairments being able to leave the facility unsupervised, placing them at risk of harm.
Failure to Submit NFSS Forms Timely Delays PASRR Services
Penalty
Summary
The deficiency in the facility's operations was identified as a failure to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program, specifically in the timely submission of Nursing Facility Specialized Services (NFSS) forms. This failure affected five residents who required PASRR services, potentially delaying their access to necessary specialized services such as occupational therapy (OT), physical therapy (PT), speech therapy (ST), and durable medical equipment (DME). The report highlights that the NFSS forms were not submitted within the required timeframe, which is no more than 30 days after the assessment for the service was completed by the therapist. The report details the medical conditions and PASRR recommendations for each of the five residents involved. These residents had various diagnoses, including dementia, intellectual disabilities, cerebral palsy, schizoaffective disorder, and quadriplegic cerebral palsy. Despite having comprehensive service plans recommending specialized services, the residents did not receive these services due to the facility's failure to submit the necessary NFSS forms. Interviews with residents revealed that some had not attended therapy sessions for months, indicating a significant lapse in care. The deficiency was attributed to staff changes within the rehabilitation department, specifically the resignation of the previous Rehabilitation Director, which led to a gap in the submission of NFSS forms. The Interim Rehabilitation Director confirmed that the forms were not submitted after PASRR meetings held in January and February, resulting in a delay in starting the recommended services. The facility's policy and the Texas Health and Human Services policy both emphasize the importance of timely and accurate completion of PASRR assessments and NFSS submissions, which were not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Houston Transitional Care | 2.2 mi | ★★★★★ | 1 | 0 |
| The Lev At Town Park | 2.5 mi | ★★★★★ | 2 | 2 |
| Focused Care At Beechnut | 2.6 mi | ★★★★★ | 2 | 1 |
| University Place Nursing Center | 2.8 mi | — | 0 | 0 |
| St Dominic Village Rehabilitation And Nursing Cent | 2.9 mi | ★★★★★ | 2 | 0 |
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