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 North Houston Transitional Care during CMS and state inspections, most recent first.
A facility failed to maintain complete controlled-substance records for a resident’s hydrocodone order. The resident had rheumatoid arthritis, intact cognition, and documented pain, and the chart showed multiple PRN opioid administrations along with pharmacy deliveries and home medication brought in by family. However, the facility could not produce complete narcotic sign-out records, and staff and family accounts conflicted about how many tablets were received, used, or returned.
The facility failed to store medications and biologicals securely, as evidenced by a resident having Clotrimazole cream on their nightstand and another resident having a cup of barrier cream on their bedside tray. Both residents had cognitive impairments, and the presence of these items posed a risk. Staff interviews revealed a lack of adherence to the facility's policy on medication storage, despite previous training.
A resident with a complex medical history was admitted to an LTC facility in respiratory distress with an oxygen saturation of 73%. LVN A failed to notify the physician or follow the facility's protocol for a change in condition, resulting in a lack of guidance and the resident's subsequent death. The facility's policy required immediate physician notification, which was not adhered to.
A resident admitted in respiratory distress with low oxygen saturation was not frequently monitored by LVN A, leading to the resident being found unresponsive and passing away. CNA B observed the resident's shortness of breath but did not report it. The facility lacked protocols for monitoring residents with a change of condition, and LVN A did not notify the DON or physician of the resident's condition.
A resident with pressure ulcers did not receive proper wound care as per physician's orders, leading to potential infection risks. The facility's staff failed to follow prescribed wound care procedures, including incorrect dressing application and inadequate hand hygiene. Interviews revealed a lack of training and communication regarding wound care protocols.
A resident with a history of sepsis and pressure ulcers received improper wound care from an LVN who failed to perform hand hygiene and did not follow physician's orders. The LVN used unauthorized treatments and admitted to not receiving proper training, highlighting a deficiency in the facility's infection control program.
A resident with severe cognitive impairment and multiple medical conditions fell from bed due to an unsecured air mattress. The facility failed to ensure the mattress was properly strapped to the bed frame, resulting in the resident being sent to the hospital for evaluation. Maintenance staff were responsible for securing the mattresses, but the oversight was discovered by a nurse responding to a beeping sound in the resident's room.
Incomplete Controlled Substance Records for Resident Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of controlled substances for one resident. The resident was an elderly female admitted with rheumatoid arthritis, intact cognition by BIMS, and documented pain with an opioid order for hydrocodone-acetaminophen 10/325 mg every 8 hours as needed. The resident’s record showed multiple administrations of hydrocodone during the stay, and the facility also documented that the resident was taking an opioid medication on the admission MDS. Record review showed the facility received hydrocodone deliveries from the pharmacy, including tablets delivered on 4/27/26 and 5/10/26, and there was also documentation that the resident’s family gave the facility 7 tablets from home supply on admission. The MAR documented 27 total doses administered during April and May 2026, but the facility was unable to provide complete narcotic sign-out records for the resident’s hydrocodone except for the 7 tablets received from home supply. The surveyor also found that the medication cart did not contain narcotic records for the resident, and the DON stated she could not find the narcotic records after the resident discharged. The record also showed inconsistencies between medication receipt, sign-out documentation, and family reports. A progress note documented that the family gave a dose of Norco while awaiting pharmacy delivery, and family emails stated the facility had run out of the medication and asked about returning leftover tablets they had provided. The family later reported giving 7 tablets and then 20 additional tablets to the facility, but the facility had no documentation for the additional tablets. Staff interviews reflected differing recollections about whether the resident’s hydrocodone was available, whether it was pulled from the automated dispensing system, and whether home medication was counted and documented. The facility policy required records for receipt, dispensing, and disposition of controlled substances, and required completed medication disposition records to be kept on file.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for two residents. For Resident #3, a box containing Clotrimazole 1% cream was found on his nightstand. This resident, who had cognitive impairment and was not prescribed this medication, was at risk due to the presence of the cream. The Interim DON confirmed that the cream was brought in by the resident's family and should not have been at the bedside. For Resident #12, a medication cup filled with an unidentified white barrier cream was found on the bedside tray. This resident had severe cognitive impairment and was at risk due to the presence of the cream. The Wound Care Nurse stated that the cream was Triad Hydrophilic wound dressing with zinc oxide and should not have been left in the room. The Interim DON and ADON acknowledged that the cream should not have been in the room and that staff were responsible for ensuring such items were not accessible to residents. Interviews with staff revealed that there was a lack of adherence to the facility's policy on the storage of medications and biologicals. The facility's policy required that all drugs and biologicals be stored in locked compartments, and staff were expected to notify a nurse if they found any medications or creams in residents' rooms. Despite previous training and in-services, the staff did not consistently follow these procedures, leading to the deficiencies observed.
Failure to Notify Physician of Resident's Respiratory Distress
Penalty
Summary
The facility failed to immediately inform or consult with a resident's physician when there was a significant change in the resident's physical condition. A resident, who was admitted to the facility from a rehabilitation hospital, was observed by LVN A to be in respiratory distress with an oxygen saturation level of 73% upon admission. Despite this critical condition, LVN A did not notify or seek clinical guidance from the resident's physician or any physician, which resulted in a lack of communication and guidance regarding the resident's care. The resident had a complex medical history, including chronic congestive heart failure, atherosclerotic heart disease, diabetes with polyneuropathy, chronic kidney disease, and other serious conditions. Upon admission, the resident was not prescribed scheduled or PRN oxygen therapy, and there was no documentation of a care plan in the clinical records. LVN A attempted to stabilize the resident by administering oxygen, which temporarily improved the resident's condition. However, the resident was later found unresponsive and subsequently expired. Interviews with facility staff revealed that there was a lack of adherence to the facility's protocol for notifying a resident's physician of a change in condition. LVN A did not follow the proper chain of command and failed to notify the DON or the resident's physician about the initial respiratory distress. The facility's policy required immediate notification of the physician in such cases, but this was not done, contributing to the resident's deterioration and eventual death.
Failure to Monitor and Assess Resident in Respiratory Distress
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of the residents reviewed for quality of care. A resident was admitted from a rehabilitation hospital in respiratory distress with an oxygen saturation of 73%. LVN A administered 5L of oxygen and assumed the resident's condition was stable without frequent monitoring or assessment throughout her shift. This lack of monitoring resulted in the resident being found unresponsive later in the day and subsequently passing away. CNA B observed the resident experiencing shortness of breath multiple times during her shift but failed to inform LVN A or any nursing staff of the resident's need for nursing assessment. Despite being aware of the resident's earlier respiratory distress and clinical interventions, CNA B did not report these observations, contributing to the lack of timely intervention. Interviews with facility staff revealed that LVN A did not follow protocol by notifying the DON or the resident's physician about the resident's initial low oxygen saturation and change of condition. Additionally, LVN A did not closely monitor the resident due to being overwhelmed with other duties and a perceived lack of nursing staff. The facility lacked protocols for frequent monitoring of residents experiencing a change of condition, which further contributed to the deficiency.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent infection for a resident with pressure ulcers. The resident, a male with a history of sepsis, stage 4 pressure ulcer of the sacral region, and chronic kidney disease, was observed to have his wound dressings not changed according to the physician's orders. Specifically, the dressings for the resident's posterior right knee Stage 3 and Sacrococcyx Stage 4 pressure ulcers were not changed as prescribed, which could lead to infection and other health complications. The Wound Care Nurse did not transcribe the wound care doctor's order dated 8/13/24 for the resident, leading to incorrect wound care being administered. During an observation, an LVN was seen providing wound care without following the physician's orders, using incorrect materials, and failing to perform proper hand hygiene, which could result in cross-contamination. The LVN admitted to not receiving training or a competency check on wound care at the facility and was unaware of the wound care doctor's evaluations. Interviews with facility staff revealed a lack of communication and access to the wound care doctor's evaluations, leading to improper wound care practices. The ADON acknowledged that the Wound Care Nurse was responsible for reviewing and transcribing the wound care doctor's orders, but this was not done. The facility's procedures for wound care were not followed, as evidenced by the lack of hand hygiene and incorrect application of wound care materials, highlighting a systemic issue in the facility's wound care management.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN Z during wound care for a resident. The resident, a male with a history of sepsis, stage 4 pressure ulcers, and chronic kidney disease, was observed receiving wound care from LVN Z. During the procedure, LVN Z did not perform hand hygiene after removing soiled gloves and before donning clean ones, which is a critical step in preventing cross-contamination and infection spread. Additionally, LVN Z did not follow the physician's orders for wound care. Instead of applying the prescribed Silvasorb gel and betadine, LVN Z used collagen powder and hydrogel, which were not ordered. This deviation from the prescribed treatment could potentially impact the resident's wound healing process. Furthermore, LVN Z admitted to not receiving proper training or competency checks for wound care at the facility, which contributed to the improper handling of the wound care procedure. The facility's infection control policies, which emphasize hand hygiene as a primary means to prevent healthcare-associated infections, were not adhered to by LVN Z. The facility's ADON, who is a certified infection preventionist, acknowledged the lapse in infection control practices and noted that LVN Z had not signed the in-service training report on hand hygiene. This indicates a gap in ensuring that all staff are adequately trained and compliant with infection control protocols.
Failure to Secure Air Mattress Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically by not securely strapping a resident's air mattress to the bed frame. This oversight resulted in the mattress, along with the resident, falling off the bed frame onto the floor. The resident, a male with severe cognitive impairment and multiple medical conditions including dementia, reduced mobility, and pressure ulcers, was sent to the hospital for evaluation following the incident. The resident was dependent on all activities of daily living and mobility, and had not experienced any previous falls. The incident was discovered when a nurse heard beeping from the resident's room and found the resident on the floor wrapped in sheets, with the air mattress standing on the side of the bed. The nurse noted that the mattress was not secured to the bed frame, which was supposed to be the responsibility of the maintenance staff. Interviews with staff revealed that the maintenance team was responsible for securing air mattresses, but the nurse typically assumed they were secured if already in place. The Director of Nursing confirmed that the maintenance staff was responsible for securing the mattresses, and that the incident led to a facility-wide check of all air mattresses. The facility's records indicated that the resident was assessed as a low risk for falls, and there was no order for the air mattress, although it was standard practice to use them for residents with Stage II pressure ulcers or higher. The facility's policy on assessing falls and their causes emphasized the importance of identifying risk factors and completing incident reports promptly. However, a specific policy on air mattresses was not provided upon request.
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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) |
|---|---|---|---|---|
| Misty Willow Healthcare And Rehabilitation Center | 0.4 mi | ★★★★★ | 16 | 5 |
| Champions Healthcare At Willowbrook | 1.3 mi | ★★★★★ | 14 | 0 |
| Fallbrook Rehabilitation And Care Center | 3 mi | ★★★★★ | 17 | 4 |
| Park Manor Of Cyfair | 3 mi | ★★★★★ | 1 | 0 |
| Cypress Creek Rehabilitation And Healthcare Center | 4 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.