Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakmont Healthcare And Rehabilitation Center Of Ka during CMS and state inspections, most recent first.
A resident with a history of traumatic brain injury and high fall risk did not receive required 1:1 supervision when the assigned CNA fell asleep, resulting in the resident being left unsupervised and experiencing a fall. Staff interviews and documentation confirmed that the resident required constant monitoring due to agitation and unsteady gait, but the CNA failed to remain alert and within arm's reach as required by the care plan.
A resident with multiple complex medical conditions was admitted without an accurate weight being obtained at the facility. The MDS Coordinator used the hospital discharge weight for the admission MDS assessment instead of a current measurement, as the resident was not weighed upon arrival due to agitation and lack of follow-up by staff. The actual weight was documented several days later, revealing a significant discrepancy. Staff interviews confirmed that facility protocols for accurate assessment and interdisciplinary communication were not followed.
The facility failed to ensure proper disposal of garbage by not keeping the dumpster door closed when not in use, as observed during a survey. A commercial-sized dumpster was found open and three-quarters full, posing a risk of pest entry. The Director of Food and Nutrition acknowledged the issue, and it was noted that staff from dietary, nursing, and housekeeping were responsible for closing the dumpster doors. The facility also lacked a policy for garbage disposal, as confirmed by the Administrator.
The facility failed to maintain privacy for residents by not placing Foley catheter bags in privacy bags and not providing privacy curtains between shared beds. A resident with chronic kidney disease and another with cancer had their catheter bags exposed, contrary to care plans. Additionally, two residents with cognitive impairments shared a room without a privacy curtain, leading to discomfort. Staff were unaware of these oversights, highlighting a lapse in maintaining resident dignity.
The facility failed to store and label food items in accordance with professional standards, as observed in their kitchen. Several food items in the refrigerator were not properly labeled with use-by dates or were past their expiration dates, including cream cheese, deli meats, cheeses, canned beets, and beef stew. The Dietary Food Service Manager acknowledged the responsibility to ensure proper labeling and discarding of expired items, as per the facility's 2012 food safety policies.
A facility failed to submit a final investigation report to the State Survey Agency within the required timeframe following an abuse allegation involving a resident with hemiplegia and cognitive impairment. The initial report was submitted, but the final report was not, due to an oversight by the former DON. The current Administrator confirmed the investigation was completed but not submitted, and the new DON had not been trained in report submission.
A resident with multiple medical conditions, including diabetes, was not provided with a comprehensive care plan addressing foot care needs. Despite a physician's order for podiatry consults, the resident's care plan lacked podiatry services, and observations showed neglected toenail care. Facility staff interviews revealed communication gaps and unclear responsibilities in updating care plans, leading to the oversight.
A resident with diabetes did not receive necessary podiatry services, leading to long and thick toenails. Despite a physician's order for podiatry consults, the resident was not on the list for services due to communication and procedural failures among staff. Observations and interviews revealed systemic issues in the facility's process for ensuring proper foot care.
A resident with severe cognitive impairment and a history of cerebral infarction was found to have her oxygen concentrator set at 3.5 liters, contrary to the physician's order of 1-2 liters. The RN responsible did not verify the setting during rounds, and the NP was not informed of the change, violating the facility's policy on oxygen administration.
A medication aide in an LTC facility failed to adhere to prescribed parameters by attempting to administer Carvedilol to a resident with a heart rate below the ordered threshold. The resident, with conditions such as atrial fibrillation and hypertension, was at risk due to this oversight. The error was identified during a surveyor's observation, and interviews confirmed the aide's failure to follow the facility's medication administration policies.
A facility failed to maintain an effective infection control program, as evidenced by the absence of signage for a resident on enhanced barrier precautions and improper labeling of personal care items in a shared room. A resident with multiple indwelling devices lacked appropriate infection control signage, and a hairbrush was found unlabeled at a sink, risking cross-contamination. Staff interviews confirmed the lapses in protocol adherence.
The facility did not post the most recent survey results in a location accessible to residents and families. The survey results were kept in a binder at the front desk, but residents were unaware of their location. The administrator admitted the signage was missing and later found it, placing it on the wall with the inspection binder.
A resident with a history of muscle weakness, Type 2 Diabetes Mellitus, and a history of stroke did not receive weekly skin assessments over several periods, as required by their care plan. Despite the resident's moderate risk for pressure sores and documented need for regular skin checks, the facility failed to document these assessments. Interviews with staff confirmed the oversight, and the facility's policies on skin integrity management were not followed.
A resident in an LTC facility was left without incontinence care for over seven hours, resulting in skin irritation and discomfort. The resident, who required assistance with daily living activities, was found double-briefed with heavily soiled briefs. Despite the care plan requiring care every two hours, the CNA failed to provide the necessary care, citing the resident's therapy session as a reason. Interviews revealed a lack of adherence to care plans and facility policies, contributing to the deficiency.
A resident on hospice care did not receive prescribed morphine 15mg ER for two days due to the facility's failure to transcribe and administer the medication timely. The DON did not process the hospice orders promptly, and LVN A did not verify the medication orders upon receipt. This oversight risked the resident's comfort and pain management.
Failure to Provide Adequate 1:1 Supervision Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a significant history of falls, traumatic brain injury, and cognitive impairment did not receive adequate supervision as required by their care plan. The resident was on 1:1 supervision due to agitation, unsteady gait, and a recent subdural hematoma, with interventions in place such as a low bed, fall mats, and a helmet. Despite these measures, the assigned CNA responsible for 1:1 supervision fell asleep while on duty, leaving the resident unsupervised. During the period of unsupervised care, the resident was able to get up and subsequently fell. The incident was initially reported by the CNA as an assisted transfer where the resident sat on the floor, but later investigation and interviews revealed that the CNA had dozed off and was not truthful in the initial account. The resident was found on the floor, and the event was later classified as an unwitnessed fall due to the lack of supervision. The resident was assessed and sent to the hospital for evaluation, given his prior history of head injury and the unwitnessed nature of the fall. Interviews with staff confirmed that 1:1 supervision required the staff member to always have the resident in eyesight and remain within arm's reach, and that sleeping while on duty was not permitted. The CNA admitted to falling asleep, and staff interviews corroborated that the resident was at high risk for falls and required constant monitoring. The facility's failure to ensure the CNA remained awake and provided the necessary supervision directly led to the resident's fall while under 1:1 supervision.
Inaccurate MDS Weight Documentation on Admission
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's weight status at admission. Specifically, the admission MDS for a male resident with multiple complex diagnoses, including traumatic brain injury, malnutrition, and dysphagia, documented his weight as 154 pounds, which was taken from hospital records rather than an actual weight measurement at the facility. The resident's weight was not obtained upon admission due to his agitation, and the admitting nurse deferred the task to another staff member, who did not complete it. As a result, the MDS Coordinator used the hospital discharge weight to complete the assessment for billing purposes, without verifying the resident's current weight at the facility. Record reviews showed that the resident's actual weight was not documented until several days after admission, at which point it was recorded as 138 pounds. The nurse's notes at admission indicated that no weight was documented, and the MDS Coordinator later acknowledged that she should have ensured the resident was weighed at the facility before completing the MDS. The facility's policy requires comprehensive and accurate assessments using the RAI process, with all disciplines following the guidelines for coding each assessment, but this protocol was not followed in this instance. Interviews with staff revealed a lack of communication and follow-through regarding the resident's weight assessment. The admitting nurse was unaware that the weight had not been obtained, and the MDS Coordinator admitted to relying on hospital records instead of current facility data. The Director of Nursing stated that nurses are expected to conduct proper assessments, including reviewing CNA documentation and nurse progress notes, but this was not done for this resident's admission weight.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically by not ensuring that the dumpster door was closed when not in use. This was observed during a survey, where a commercial-sized dumpster located behind the dietary department was found to be three-quarters full with its door open. The Director of Food and Nutrition confirmed that the dumpster door should remain closed to prevent pests from entering the dumpster and potentially the facility. It was noted that staff from dietary, nursing, and housekeeping were responsible for ensuring the dumpster doors were kept closed. Additionally, the facility lacked a policy and procedure for the disposal of garbage and refuse, as confirmed by the Administrator.
Privacy Violations in Resident Care
Penalty
Summary
The facility failed to ensure personal privacy for several residents, specifically in the handling of Foley catheter bags and the provision of privacy curtains. For Resident #45, a male with chronic kidney disease and other severe health conditions, the CNA responsible did not place the Foley catheter bag inside a privacy bag as required by the resident's care plan and physician's orders. This oversight was observed on multiple occasions, and the CNA admitted to not being aware of the requirement until informed by the Assistant Director of Nursing (ADON). Similarly, Resident #175, a female with cancer and other health issues, also had her Foley catheter bag left outside of a privacy bag. The resident expressed a preference for the bag to be concealed, especially during family visits. The CNA responsible for her care was unaware of the oversight, and both the ADON and the Director of Nursing (DON) acknowledged the importance of using privacy bags to maintain resident dignity. Additionally, the facility failed to provide a privacy curtain between the beds of Resident #9 and Resident #5, both of whom have cognitive impairments and other health issues. This lack of privacy was noted during an observation, and Resident #9 expressed discomfort with the situation. The facility's administration initially believed the room was private, which led to the absence of a curtain. However, it was later confirmed that the room was shared, and the residents were subsequently moved to different rooms.
Food Safety Deficiency in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen. During an inspection, it was found that several food items in the refrigerator were not properly labeled with use-by dates or were past their expiration dates. Specifically, an open box of cream cheese was dated 10/30/24 without a use date, sliced deli meat and Swiss cheese were dated 11/01/24, shredded mozzarella cheese was found with dates of 10/15 and 11/06/24, and sliced deli ham had no label or date. Additionally, canned beets and beef stew were stored in plastic containers with dates indicating they were past their use-by dates. In an interview, the Dietary Food Service Manager acknowledged her responsibility to ensure that dietary staff label and date food items and discard them before expiration. The facility's policies and procedures for food safety, dated 2012, require that perishable opened food be used within seven days or less to comply with the Texas Food Establishment rules. The failure to follow these procedures could place residents at risk of foodborne illness and disease.
Failure to Submit Final Investigation Report for Abuse Allegation
Penalty
Summary
The facility failed to report the results of an investigation into an allegation of abuse involving a resident to the State Survey Agency within the required five working days. The incident involved a resident who alleged that a CNA was rough during a transfer. Although the initial incident report was submitted, the final investigation report was not submitted as required. The resident involved was an elderly male with a history of hemiplegia and hemiparesis following a stroke, requiring substantial assistance with activities of daily living due to moderate cognitive impairment. Interviews with facility staff revealed that the former Director of Nursing (DON) believed the final report had been submitted, but it was not. The current Administrator confirmed the oversight and acknowledged that the investigation was completed but not submitted. The newly hired DON had not yet been trained to submit reports into the Tulip system. The facility's policy and state guidelines require that such incidents be reported and investigated, with a final report submitted within the specified timeframe.
Failure to Include Podiatry Services in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident, specifically neglecting to address the resident's need for foot care. The resident, a male with diagnoses including Alzheimer's Disease, cerebral infarction, hemiplegia, hemiparesis, and type 2 diabetes mellitus, was admitted to the nursing facility in October 2023. Despite having a physician's order for podiatry consults as needed, the resident's care plan did not include podiatry services, and he was not listed for podiatry services scheduled for October 2024. Observations revealed the resident's toenails were thick, long, and beginning to curve, indicating a lack of necessary foot care. Interviews with facility staff, including the MDS Coordinator, ADON, DON, and Social Worker, revealed a lack of communication and responsibility in updating the resident's care plan to include podiatry services. The MDS Coordinator was responsible for initial and quarterly care plans, while unit nurses, ADON, or DON were expected to make revisions. However, the Social Worker was not informed of the resident's need for podiatry services, resulting in the omission from the care plan. The facility's policy on comprehensive centered care plans emphasizes the need for interdisciplinary collaboration to meet residents' needs, which was not adhered to in this case.
Failure to Provide Adequate Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with diabetes mellitus, which placed the resident at risk for injuries and infections. The resident, a male with Alzheimer's Disease, cerebral infarction, hemiplegia, hemiparesis, and type 2 diabetes mellitus, was not included in the list for podiatry services despite having a physician's order for a podiatry consult as needed. Observations revealed that the resident's toenails were thick, long, and beginning to curve, indicating a lack of proper foot care. Interviews with staff members, including CNAs, the ADON, and the Social Worker, revealed a breakdown in communication and procedure. The CNAs were responsible for reporting the need for toenail clipping to the nurses, who would then contact the Social Worker to add the resident to the podiatry list. However, this process was not followed, as the CNAs either forgot to report or could not recall to whom they reported the need for toenail care. The Social Worker confirmed that the resident was not on the list for podiatry services, and the last visit from podiatry services was over a month prior. Further interviews with the LVN and DON highlighted systemic issues in the facility's process for ensuring residents received necessary podiatry care. The LVN admitted to not performing a head-to-toe assessment on the resident due to a lack of system triggers, and the DON acknowledged the need for staff in-servicing and process improvements. The facility's policy on foot care emphasized the importance of regular assessments and referrals to podiatry services, especially for residents with diabetes, but these procedures were not effectively implemented, leading to the deficiency.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in the administration of oxygen therapy. The resident, a female with a history of cerebral infarction, hypertension, and cerebrovascular disease, was supposed to receive oxygen at 1-2 liters per minute via nasal cannula to maintain oxygen saturation levels above 92%, as per physician's orders. However, during an observation, it was found that the resident's oxygen concentrator was set at 3.5 liters, which was higher than the prescribed amount. The resident, who had severely impaired cognition, was unable to confirm if she had changed the setting herself. Interviews with the nursing staff revealed that the registered nurse (RN) responsible for the resident's care was unaware of the correct oxygen setting and admitted to not checking the concentrator during her initial rounds. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the oxygen setting should be checked every two hours during rounds, and the physician should be notified before any changes to the oxygen setting are made. The nurse practitioner (NP) was not informed of the increased oxygen setting, which was against the facility's policy. The facility's policy on oxygen administration requires adherence to the physician's orders, which was not followed in this case.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a medication aide, MA Y, attempted to administer Carvedilol 3.125 mg to a resident with a heart rate of 59, which was below the ordered parameter of holding the medication if the pulse was less than 60. The resident, an elderly female with diagnoses including paroxysmal atrial fibrillation, hypertension, and angina pectoris, was at risk of adverse effects due to this error. The medication order specifically required the medication to be held if the resident's heart rate was below 60, a parameter that was not adhered to during the medication administration process. During the medication observation, the surveyor intervened to prevent the administration of the medication, highlighting the failure of MA Y to follow the prescribed parameters. Interviews with MA Y, the DON, and the ADON revealed that MA Y acknowledged the error and understood the potential consequences of administering the medication under these conditions. The facility's pharmacy policy and procedure manual emphasized adherence to the five rights of medication administration, which MA Y failed to follow, leading to the potential risk of harm to the resident.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of infection control signage on the door of a resident with multiple indwelling devices and wounds. This resident, a male with chronic kidney disease, functional quadriplegia, heart disease, and stage 4 pressure ulcers, was on enhanced barrier precautions due to his medical conditions. Despite the presence of personal protective equipment (PPE) outside the resident's room, there was no signage to alert staff and visitors of the necessary precautions, which was confirmed through observations and staff interviews. Additionally, the facility did not properly label and store personal care items for two residents sharing a semi-private room. A hairbrush belonging to one resident was found at the sink area without any labeling, indicating it as personal property. Interviews with the resident and staff revealed that the brush was mistakenly placed there by a staff member, and there was an expectation that personal items should be stored separately and labeled to prevent cross-contamination. The facility's infection control policy was reviewed, but a specific policy regarding the handling of residents' personal property in rooms was not provided. Interviews with various staff members, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), highlighted the responsibility of ensuring infection control signage and proper labeling of personal items to prevent the spread of infections. However, these protocols were not consistently followed, leading to the identified deficiencies.
Failure to Post Survey Results in Accessible Location
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was readily accessible to residents, family members, and legal representatives. During an observation, it was noted that the last survey results were kept in a binder at the front desk outside the administrator's office. However, residents were unaware of the location of these reports, as revealed during a confidential group meeting. The administrator acknowledged that the signage indicating the location of the inspection reports was missing and stated that it had been taken by a resident earlier that day. The administrator was responsible for ensuring the survey results were available for public review but was unable to locate the signage during the surveyor's visit. The administrator later found the frame and placed it on the wall near the front desk with the inspection binder. The facility's policy mandates the posting of inspection reports and related documents, but the failure to maintain this accessibility placed residents and their families at risk of not being able to review the findings from state surveys and investigations without having to request them.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to provide weekly skin assessments for a resident over several periods, specifically from 2/12/2024 through 3/2/2024, 3/27/2024 through 4/13/2024, and 4/27/2024 through 5/11/2024. This lapse in care was identified through observation, interviews, and record reviews. The resident, an elderly male with a history of muscle weakness, Type 2 Diabetes Mellitus, and a history of stroke, required substantial assistance with daily activities and had a documented need for regular skin assessments due to conditions like incontinence-associated dermatitis and a moderate risk of developing pressure sores. The resident's care plan included interventions for maintaining skin integrity and preventing complications related to diabetes, which necessitated regular skin checks and prompt treatment of any skin issues. Despite these requirements, the facility did not document the necessary weekly skin assessments during the specified periods. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Compliance Nurse, confirmed the absence of these assessments and highlighted the potential risks of missing such evaluations, including skin breakdown and infection. The facility's policies on skin integrity management and pressure injury prevention emphasized the importance of regular assessments and documentation of any changes in skin condition. However, the lack of adherence to these policies was evident in the missing documentation for the resident's weekly skin assessments. The Compliance Nurse acknowledged the oversight and the potential consequences of not conducting these assessments, which could lead to serious health complications for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary care for a resident who was unable to perform activities of daily living, specifically incontinence care. The resident, an elderly male with a history of cerebral infarction, paralytic syndrome, and other medical conditions, was found to have been left without incontinence care for over seven hours. This neglect was observed when the resident was found double-briefed with heavily soiled briefs containing urine and feces, leading to skin irritation and discomfort. The resident's care plan required incontinence care every two hours, which was not adhered to by CNA A, who admitted to not providing the necessary care due to the resident being in therapy and other unspecified reasons. The CNA also acknowledged that double-briefing was not a good hygiene practice and exposed the resident to potential infections. Despite the resident's care plan and physician orders, the facility staff failed to follow through with the required interventions, resulting in the resident experiencing discomfort and skin irritation. Interviews with facility staff, including the LVN and DON, revealed a lack of adherence to the care plan and facility policies. The DON, who was new to the facility, had care planned the resident for double-briefing based on a misunderstanding of the resident's preferences. However, both the resident and their representative denied any request for double-briefing. The facility's failure to provide timely incontinence care and the inappropriate use of double-briefing contributed to the deficiency observed by the surveyors.
Failure to Administer Hospice Medication Timely
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in a delay in medication administration. The Director of Nursing (DON) did not transcribe physician orders received from hospice on October 8, 2024, until October 10, 2024. This delay affected the administration of morphine 15mg ER, which was delivered to the facility on October 8, 2024, but not given to the resident until October 10, 2024. The resident, who was on hospice care, was at risk for unwanted pain and discomfort due to this oversight. The resident involved was an elderly male with a history of dementia, heart disease, diabetes, and chronic kidney disease, among other conditions. He had been admitted to the facility on hospice services after a fall and subsequent hospital transfer. The hospice orders included discontinuation and initiation of specific medications, including morphine for pain management. However, the failure to transcribe and administer the medication as ordered led to a lapse in the resident's pain management plan. Interviews with the hospice nurse and facility staff revealed communication gaps and procedural failures. The hospice nurse had emailed the orders to the DON, who claimed not to have received them. Additionally, LVN A, who received the medication, did not verify the orders or follow up with hospice services. The facility's policy required nurses to check and transcribe new medication orders, but this was not adhered to, contributing to the deficiency.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Katy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mason Creek Transitional Care Of Katy | 0.9 mi | ★★★★★ | 1 | 0 |
| Solera At West Houston | 2.2 mi | ★★★★★ | 3 | 1 |
| Falcon Point Post Acute | 2.6 mi | ★★★★★ | 9 | 0 |
| Ignite Medical Resort Katy, Llc | 3.1 mi | ★★★★★ | 4 | 0 |
| Sterling Oaks Rehabilitation | 3.6 mi | ★★★★★ | 13 | 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.