Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Houston Heights Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to implement PASARR Level II therapy recommendations for two residents by not ensuring that ordered and PCSP-requested OT, PT, and ST services were evaluated and provided as required. One resident with severe cognitive impairment, speech and language disorders, and upper extremity impairment had PASARR and physician orders for specialized OT, PT, and ST, but only received ST evaluation and no PT or OT evaluations. Another resident with intellectual disability, dysphagia, parkinsonism, muscle wasting, contractures, and schizophrenia had ongoing specialized OT and new PT requested through PASARR, but only OT was evaluated and the PT evaluation on file predated the most recent PASARR request. Staff interviews showed confusion over who was responsible for initiating therapy referrals and entering PASARR information into the electronic portal, and leadership acknowledged there was no specific PASARR Level II policy and that missing entries in the system meant residents did not receive all approved services.
A resident with hemiplegia, hemiparesis, diabetic neuropathy, multiple contractures, dementia, and total dependence for ADLs had physician orders for an air pressure-reducing mattress and bilateral heel protectors, and staff reported using pillows, a special bolster, rolled towels, and soft booties during care. Observations showed severe contractures of an upper extremity and both lower extremities, pain with movement during incontinent care, and only one heel protector in use. Record review revealed that the comprehensive care plan did not include a problem or interventions for the resident’s documented contractures and did not include the ordered heel protectors as an intervention for pressure-ulcer risk, despite facility leadership and MDS staff acknowledging that such active issues and interventions should be reflected in the care plan.
A resident with a history of bilateral femur fractures and paraplegia was admitted with a right knee immobilizer, but staff failed to obtain or document a physician order for the device. This omission led to confusion among nursing staff and inconsistent application of the immobilizer, as the need for the device was not clearly communicated or recorded in the resident's care plan or physician orders.
Two residents with severe cognitive impairment and psychiatric conditions were subjected to verbal abuse by the DON, who threatened one resident with jail and yelled at another in a confrontational manner. Multiple staff confirmed the DON's pattern of unprofessional and abusive behavior, which violated the facility's abuse prevention policies.
A resident with multiple sclerosis and significant mobility deficits sustained foot fractures when a CNA failed to turn off the resident's motorized wheelchair during care, resulting in the wheelchair moving forward and causing injury. The care plan did not specify this safety measure, and the CNA had not been trained on it prior to the incident.
A resident with multiple health issues experienced SOB and low oxygen levels during dialysis, but the LTC facility failed to notify the physician. The resident was sent to dialysis without an oxygen tank, despite having a PRN order for oxygen. The dialysis center staff provided oxygen, improving the resident's condition. Facility staff were aware of the need for oxygen but failed to ensure it was sent, and the NP was not informed of the incident.
A resident's family member reported that a CNA handled the resident roughly during care, including removing the oxygen cannula and clothing. Despite the family member's concerns, the facility's Administrator did not report the incident to HHSC, as it was not considered an abuse allegation. The resident, who had severe cognitive impairment and multiple health conditions, required assistance with daily activities. The facility's policy required immediate reporting of suspected abuse, which was not followed.
A resident with a history of SOB was sent to dialysis without necessary oxygen equipment, leading to desaturation and SOB. The facility also failed to send a mechanical lift pad, delaying treatment. Staff were unaware of the orders, highlighting communication gaps.
The facility failed to refer a resident with a newly evident serious mental disorder for a Level II PASARR review upon a significant change in status assessment. Despite multiple diagnoses and the administration of antipsychotic, antianxiety, and antidepressant medications, the necessary documentation and referrals were not completed, potentially placing residents at risk for not receiving necessary mental health services.
A facility failed to accurately document a resident's cognitive status and physical impairments in their assessment. The resident's MDS incorrectly noted an impairment of only one leg, omitting the amputations of both legs. This oversight was confirmed by the MDS Nurse and the DON, highlighting the importance of accurate MDS documentation for creating appropriate care plans.
The facility failed to provide proper pharmaceutical services for two residents. One resident did not receive hydrocortisone cream for two days due to incorrect order placement on the MAR, while another resident had a Lidocaine patch applied incorrectly and wore two patches simultaneously. These errors resulted from poor communication and procedural lapses among staff.
A resident with multiple medical conditions was injured during a manual transfer by one CNA, despite the care plan requiring a mechanical lift with two staff members. The facility had issues with the availability and functionality of mechanical lifts, contributing to the unsafe transfer and injury.
The facility failed to ensure that an LVN maintained a valid license to practice. Despite being aware of the expiration, the LVN continued to work full-time, administering medications and performing other tasks. The issue was discovered during an audit, revealing the license was delinquent and expired. The facility's HR Manager and DON were unaware of the expired license until the audit.
Failure to Implement PASARR Level II Therapy Recommendations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to incorporate PASARR Level II determinations and PASARR evaluation report recommendations into resident assessments, care planning, and transitions of care for two residents. For one resident, a male with developmental disorders of speech and language, lack of coordination, muscle wasting and atrophy, and upper extremity impairment, the PASARR PCSP meeting requested specialized assessments and ongoing services in OT, PT, and ST. Physician orders also authorized OT, PT, and ST to evaluate and treat as indicated. Although a speech therapy evaluation and plan of treatment were completed, the resident did not receive a PT evaluation or PT services, and he was not evaluated for OT services despite the PASARR and physician orders. For the second resident, a male with cellulitis of the lower limb, intellectual disabilities, dysphagia, parkinsonism, cognitive communication deficit, muscle wasting and atrophy of both thighs, a left hand contracture, and schizophrenia, the PASARR PCSP meeting documented ongoing specialized OT, new PT, and discontinued ST. Physician orders authorized OT, PT, and ST to evaluate and treat as indicated, and an OT evaluation and plan of treatment were completed with findings of decreased activity tolerance, reduced independence with self-care, and upper extremity weakness. However, the PT evaluation on file predated the most recent PASARR request for services, and no new PT evaluation was completed in response to the PCSP’s request for new PT services. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for initiating and submitting therapy referrals and PASARR-related documentation into the electronic portal. An LVN stated that PT services for the second resident were not sent and that the first resident refused services, and she was unsure who was responsible for ensuring referrals were sent. The DOR reported that the first resident was not evaluated for PT or OT and that the second resident did not receive PT because of his physical condition, and acknowledged that if no referral is initiated, evaluations are not completed. The DON and the Administrator both indicated they were unaware that the two residents had not received all PASARR-approved services and described that the MDS/care management team was responsible for entering and submitting requests electronically. An RN stated there was no facility policy specific to PASARR Level II and that missing information in the electronic portal had been identified during PASARR Level II audits.
Failure to Care Plan Contractures and Heel Protectors for High-Risk Resident
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple contractures and risk for pressure ulcers. Record review showed the resident had hemiplegia, hemiparesis, diabetic neuropathy, multiple documented contractures (left elbow, left hand, right and left knees), muscle wasting, dementia, and was dependent on staff for all ADLs, with frequent urinary and bowel incontinence and risk for pressure ulcers. The quarterly MDS documented severe cognitive impairment and functional limitations, and active physician orders included an air pressure-reducing mattress and bilateral heel protectors. However, the resident’s care plan for risk of pressure ulcer development did not include heel protectors/soft booties, and there was no care plan problem or interventions addressing the multiple contractures. During early-morning observation of incontinent care, surveyors noted the resident’s left elbow was bent close to the chest, the left hand and fingers were severely contracted, and both legs were flexed toward the chest with knees touching. The resident had a soft boot/heel protector only on the left foot and was on a low air loss mattress. When staff attempted to reposition and separate the knees for perineal care, the resident verbalized pain in the legs. Staff interviews confirmed that the resident frequently yelled out during care due to contractures and that staff sometimes had to stop and return later to complete ADLs. CNAs and LVNs described using pillows between the legs, rolled towels in the contracted hand, and soft booties or heel protectors, but these practices were not consistently documented as care plan interventions. Further interviews with the Director of Rehabilitation (DOR), MDS nurses, and the DON showed that therapy had previously provided contracture management, including splinting and use of a special bolster pillow behind the knees, and that the DOR had placed a blue bolster pillow behind the resident’s knees. The DOR stated the resident had severe contractures and experienced pain with minimal movement. CNAs and nursing staff were aware of the contractures and described techniques to position the resident and use the special bolster pillow and boots to reduce skin-to-skin contact and prevent worsening contractures and skin breakdown. Despite this, the MDS nurses and DON acknowledged that active contractures should have been care planned and that the care plan was intended to reflect the resident’s needs, goals, and interventions, but the resident’s contractures and ordered heel protectors were not included in the comprehensive care plan as required by facility policy.
Failure to Obtain Physician Orders for Immobilizer at Admission
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document physician orders for a resident's immediate care needs at the time of admission. The resident, an older adult female with a history of bilateral distal femur fractures, hypertension, multiple sclerosis, and paraplegia, was admitted with a right knee immobilizer in place as per hospital discharge instructions. Despite this, there was no physician order for the immobilizer documented in the facility's records upon admission or in subsequent physician order reports. Multiple staff interviews revealed that the admitting nurse did not clarify or transcribe the order for the immobilizer, and nurse managers did not verify the presence or need for the device during the admission process. Several staff members, including LVNs, CNAs, the DON, and the ADON, were either unaware of the immobilizer or did not recall seeing an order for it. The lack of a documented order led to confusion among staff regarding the application and continued use of the immobilizer, with some staff unaware that the resident required it for her fracture. Record reviews confirmed that the immobilizer was noted in the hospital discharge summary and initial progress notes, but this information was not carried over into the facility's physician orders or care plan interventions at the time of admission. The absence of a physician order for the immobilizer resulted in inconsistent care and the eventual discontinuation of its use, despite the resident's ongoing need for stabilization of her fracture.
Failure to Prevent Verbal Abuse by Director of Nursing
Penalty
Summary
The facility failed to protect two residents from verbal abuse by the Director of Nursing (DON). In one incident, the DON told a male resident with severe cognitive impairment and multiple psychiatric diagnoses that she would send him to jail if he did not "shut up." Multiple staff members, including a CNA and LVN, confirmed that the DON was verbally abusive to this resident and others, frequently using threats and rude language. The resident's care plan indicated he had a history of verbal outbursts and required redirection and a calm environment, but instead, he was subjected to threatening and confrontational behavior by the DON. In a separate incident, the DON confronted a female resident with severe cognitive impairment, schizoaffective disorder, and dementia, who was agitated and yelling at the nurse's station. The DON approached the resident, got in her face, and yelled at her to "shut up" in a harsh and belittling manner. Several staff members witnessed the DON's confrontational behavior, and it was reported that the resident appeared shocked by the interaction. The resident's care plan included interventions for behavioral outbursts and required staff to redirect her calmly, but these were not followed during the incident. Interviews with multiple staff members and review of facility records revealed a pattern of unprofessional and abusive conduct by the DON toward residents and staff. The facility's abuse policy prohibits verbal abuse and requires staff to maintain professionalism and dignity in all interactions with residents. Despite these policies, the DON's actions were found to be verbally abusive and in violation of the facility's standards, as confirmed by staff interviews and documentation.
Failure to Ensure Motorized Wheelchair Safety During Care Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who ambulated via a motorized wheelchair sustained minimally displaced fractures of the 2nd through 4th metatarsal necks after a certified nursing assistant (CNA) failed to turn off the wheelchair while providing care. The incident took place in the shower room, where the CNA, while leaning over the resident, accidentally bumped the wheelchair's joystick, causing the wheelchair to move forward and the resident's feet to strike the wall. The resident, who had a history of multiple sclerosis, bilateral hemiplegia, muscle contractures, and was dependent on staff for all activities of daily living, was cognitively intact and had been using the motorized wheelchair for five years. The care plan for the resident included interventions for safe wheelchair operation and staff assistance with mobility and personal care. However, the care plan did not specify that staff must turn off the motorized wheelchair during care, and the CNA involved reported not having received training on this safety measure prior to the incident. The resident stated that staff were supposed to turn off the wheelchair during care, but was unsure if this was consistently done before the incident. The CNA confirmed that she previously left the wheelchair on during care and only began turning it off after the incident occurred. Documentation and interviews confirmed that the incident resulted in the resident experiencing pain and requiring medical intervention, including immobilization of the affected foot. The facility's policy defined accidents and incidents but did not provide specific guidance on the safe handling of motorized wheelchairs during care. The failure to ensure the wheelchair was turned off during care directly led to the resident's injury.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant need to alter treatment for a resident who experienced a change in condition. The resident, who had a history of multiple health issues including dementia, chronic kidney disease, and congestive heart failure, experienced shortness of breath (SOB) and low blood oxygen levels during a dialysis session. Despite these symptoms, the facility did not notify the resident's physician or nurse practitioner (NP) about the change in condition. On the day of the incident, the resident was sent to dialysis without an oxygen tank, despite having a PRN order for oxygen to relieve hypoxia. Upon arrival at the dialysis center, the resident was found to be struggling to breathe with an oxygen saturation of 92%. The dialysis center staff provided oxygen, which improved the resident's condition. The facility staff, including an LVN, were aware of the resident's need for oxygen during dialysis but failed to ensure the oxygen tank was sent with the resident. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and the need for oxygen during dialysis. The resident's NP was not informed of the incident, which could have led to a change in the resident's treatment plan. The facility's policy required prompt notification of the physician in case of significant changes in a resident's condition, which was not followed in this case.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged violation of abuse to the Health and Human Services Commission (HHSC) concerning a resident who was reportedly handled roughly by a Certified Nursing Assistant (CNA) during care. The incident was brought to the attention of the facility by the resident's family member, who expressed concerns about the CNA's handling of the resident, including the removal of the resident's oxygen cannula and clothing. Despite these concerns, the facility's Administrator, who is also the abuse coordinator, did not report the incident to HHSC, as he did not consider it an abuse allegation. The resident involved was an elderly female with severe cognitive impairment and multiple health conditions, including dementia, chronic kidney disease, and congestive heart failure. The resident required assistance with activities of daily living and was on hemodialysis. During the incident, the resident's family member was present and participated in the care, becoming upset with the CNA's approach. The family member reported that the CNA was rough and impatient, particularly when changing the resident's clothing and cleaning her, which led to the family member dismissing the CNA from the care. Interviews with facility staff, including the Director of Nursing (DON) and the CNA involved, revealed differing accounts of the incident. The DON stated that the family member did not use the word 'abuse' when reporting the incident, and the facility was still investigating the matter. The CNA claimed that the family member was present during the care and that the resident did not express any discomfort. Despite the ongoing investigation, the facility's policy required immediate reporting of any suspected abuse, which was not adhered to in this case.
Failure to Provide Oxygen and Mechanical Lift Pad for Dialysis
Penalty
Summary
The facility failed to ensure that a resident with a history of shortness of breath (SOB) was sent to her dialysis treatment with the necessary oxygen equipment, resulting in an episode of desaturation and SOB. On the specified date, the resident was sent to dialysis without the oxygen equipment, despite having a physician's order for PRN oxygen to relieve hypoxia. The resident arrived at the dialysis center gasping for air, with an oxygen saturation of 92%, and appeared unwell. The dialysis center staff had to provide oxygen to stabilize her condition. Additionally, the facility failed to send the resident with a mechanical lift pad as ordered by her physician, which caused a delay in receiving her dialysis treatment. The mechanical lift pad was necessary for transferring the resident from her wheelchair to the treatment chair at the dialysis center. On two occasions, the facility neglected to send the pad, requiring the dialysis center staff to manually lift the resident, which was against their protocol and posed a safety risk. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's needs for oxygen and the mechanical lift pad on dialysis days. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) involved were not fully informed of the orders, leading to the oversight. The Director of Nursing (DON) was also unaware that sending the mechanical lift pad was a physician's order, indicating a gap in the facility's processes for ensuring compliance with care plans and physician orders.
Failure to Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly evident serious mental disorder for a Level II PASARR review upon a significant change in status assessment. Resident #33, who had multiple diagnoses including bipolar disorder, dementia, and anxiety disorder, was not referred to the appropriate state-designated authority when she was diagnosed with a mental illness. This oversight could potentially place residents at risk for not receiving necessary PASARR mental health services, which could lead to a decline in their mental health. Resident #33's records revealed that she had been administered antipsychotic, antianxiety, and antidepressant medications, and required assistance for all activities of daily living. Despite these indicators, the facility did not complete the necessary PASARR Level II evaluation. Interviews with the Director of Nursing and the MDS nurse confirmed that the facility was aware of the requirement but had not completed the necessary documentation and referrals. The MDS nurse acknowledged that Resident #33 required a new PL1 and Form 1012 to identify her primary dementia diagnosis and validate her ineligibility for PASARR services. The failure to complete the PASARR process was attributed to inaccuracies in the existing documentation and a lack of timely updates. The MDS nurse and the Traveling MDS Nurse admitted that the facility had other residents with similar issues, indicating a broader problem with the PASARR process. Despite the resident receiving psychiatric care services at the facility, the lack of proper PASARR documentation and referral was a significant deficiency that needed to be addressed to ensure compliance and proper care for residents with mental health needs.
Inaccurate Documentation of Resident's Cognitive and Physical Impairments
Penalty
Summary
The facility failed to accurately document the cognitive status and physical impairments of a resident in their assessment. Specifically, the assessment for a resident with multiple severe conditions, including cerebral infarction, malnutrition, heart failure, and amputations of both legs below the knees, did not accurately reflect his impairments. The resident's quarterly MDS incorrectly noted an impairment of only one leg and did not document the amputations of both legs. This discrepancy was identified during a review of the resident's face sheet, care plan, and MDS, as well as through interviews with the Director of Nursing (DON) and the MDS Nurse. The MDS Nurse admitted to an oversight in completing the resident's MDS, acknowledging that the assessment should have documented the amputations of both legs. The DON confirmed that accurate MDS documentation is crucial for creating appropriate care plans. Observations revealed that the resident was non-responsive, had visible contractions in both hands, and was dependent on a G-Tube for nutrition. The facility's Resident Assessment Policy mandates that all information in the MDS assessment should reflect resident observations and interviews, which was not adhered to in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents. For Resident #67, the facility did not correctly order and administer hydrocortisone cream as prescribed. The medication was incorrectly placed on the Medication Administration Record (MAR) for Medication Aides (MAs) instead of the Nurse MAR, leading to a delay in administration. The resident did not receive the medication for two days, despite having a rash on his right thigh that required treatment. Interviews with staff revealed a lack of communication and procedural errors in transferring the medication order to the correct MAR, resulting in the resident not receiving the necessary treatment in a timely manner. For Resident #301, the facility failed to properly apply and manage a Lidocaine patch as per the physician's orders. The Medication Aide (MA) applied the patch to the resident's right knee instead of the left thigh and did not remove the previous patch before applying the new one. This resulted in the resident wearing two patches simultaneously, which is against the manufacturer's instructions and could lead to overmedication. The MA admitted to not checking for an existing patch before applying a new one and acknowledged the mistake. The Director of Nursing (DON) confirmed that staff should follow the physician's orders and check for old patches before applying new ones. These deficiencies highlight significant lapses in the facility's medication administration processes, including incorrect order entry, poor communication among staff, and failure to adhere to physician orders and manufacturer instructions. These lapses could potentially lead to inadequate therapeutic outcomes and worsened health conditions for the residents involved.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure that the resident environment remained free of accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not use the mechanical lift as required for a resident who needed a two-person transfer using the mechanical lift. Instead, the resident was transferred manually by one CNA, resulting in the resident sustaining a tibial plateau fracture to the right knee. This incident was identified as Immediate Jeopardy by the surveyors. The resident involved had multiple medical conditions, including multiple sclerosis, paralysis, contractures, and dementia, and was dependent on helpers for transfers. The resident's care plan and physician orders specified the use of a mechanical lift with two staff members for transfers. However, on the day of the incident, the CNAs could not locate the mechanical lift, and one CNA decided to transfer the resident manually, against the care plan and physician orders. This improper transfer caused the resident significant pain and injury, leading to hospitalization. Interviews and observations revealed that there were issues with the availability and functionality of mechanical lifts in the facility. Some mechanical lifts were not working, and there was confusion among staff about the location and accessibility of the lifts. The facility's maintenance and administrative staff were aware of these issues but had not resolved them in a timely manner. This lack of proper equipment and communication contributed to the unsafe transfer and subsequent injury of the resident.
Failure to Ensure Valid Nursing License
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN A) maintained a valid license to practice. LVN A's license expired, and despite being aware of the expiration, continued to work full-time, administering medications and performing other LVN tasks. The issue was discovered during an audit of licenses, which revealed that LVN A's license was delinquent and expired. LVN A had attempted to renew the license online but faced issues with the Texas Board of Nursing's system and did not receive the necessary confirmation to proceed with the renewal. Despite multiple attempts to contact the Board, LVN A was unable to resolve the issue before the license expired. The facility's HR Manager and Director of Nursing (DON) were unaware of the expired license until the audit was conducted. The HR Manager, who had recently started working at the facility, stated that licenses were checked monthly, but she did not know when the last audit was conducted before her tenure. The DON confirmed that she did not receive any reports regarding LVN A's license status. The Administrator acknowledged that it was the staff's responsibility to ensure their licenses were renewed on time and stated that LVN A would be referred to the Board of Nursing. The facility's policies required employees to present valid licenses and certifications as a condition of employment and to provide recertifications before the expiration of current licenses. However, these policies were not effectively implemented, leading to the deficiency.
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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) |
|---|---|---|---|---|
| Caraday Of Houston | 2.9 mi | ★★★★★ | 1 | 0 |
| West Janisch Health Care Center | 3.5 mi | ★★★★★ | 19 | 4 |
| Ashford Gardens | 3.7 mi | ★★★★★ | 24 | 0 |
| Avir At Veterans Memorial | 4.1 mi | ★★★★★ | 22 | 3 |
| Paradigm At Woodwind Lakes | 4.8 mi | — | 22 | 1 |
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