Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Of Humble during CMS and state inspections, most recent first.
Dirty privacy curtain and stained bed linen were observed in 2 resident rooms. One resident with stroke, hemiplegia, diabetes, and frequent incontinence had a privacy curtain with multiple orange-brown stains, and the resident and CNA both said it was dirty. Another resident with dementia, stroke, hemiplegia, and pressure ulcers had an unoccupied bed with a white bedspread stained brown and black. The HS stated the curtain and blanket should have been clean, and the Administrator said linens and privacy curtains were expected to be clean and free of stains.
Medication administration errors exceeded the allowed rate, with surveyors finding a 19% error rate during observed med passes. An LVN gave insulin to a resident with DM at the wrong time after relying on the paper order sheet instead of the eMAR, and another LVN administered multiple g-tube meds to a resident with a feeding tube without flushing between doses as ordered. The DON stated meds should be given per order and reviewed from the eMAR, and enteral meds should be flushed per MD order.
Care Plan Missing Interventions for Hand Contracture: A resident with MS, tremor, muscle weakness, impaired coordination, and mild cognitive impairment had a left-hand contracture, but the care plan did not include interventions for it. The resident was observed in bed with the contracture and no brace in place, stated he sometimes had pain and could not fully open his hand, and staff interviews confirmed the condition should have been reflected in the care plan.
A resident with dementia, incontinence, and dependence for toileting and transfers reported that during incontinent care her face was pressed against a nightstand when CNAs turned her over, causing discomfort to the right side of her jaw. One CNA acknowledged the resident’s face was placed on the nightstand, while another said it was only close to the nightstand and did not touch it. The former DON later noted the resident had swelling to the right side of her face and an x-ray showed no acute fracture or dislocation.
Oxygen Not Set Per Physician Order: A resident with chronic respiratory failure, SOB, and hospice services had an order for oxygen at 3 L/min via nasal cannula, but observations showed the concentrator set at 4 L/min and, at another time, the cannula off the resident's face and draped out of reach. The resident said the oxygen helped her breathing and sometimes hurt the back of her ears, and the LPN stated he was responsible for ensuring the oxygen was set correctly per the physician order.
A resident with a history of stroke, hemiplegia, and contractures had MD orders and a care plan for daily use of a left knee splint and left hand orthotic to be worn for several hours as tolerated, with monitoring for skin issues. The MAR showed these splints as applied every day, largely documented by an LVN, yet surveyor observations found the resident without either splint in place and with contracted lower extremities. The LVN later admitted he had not applied the splints for an extended period, sometimes forgot about them, could not locate the hand splint after a room change, and had charted them as done when they were not. Other staff reported rarely or never seeing the splints in use, despite facility policy requiring review of orders and documentation of all splint care and resident response.
A resident with a history of stroke, contractures, hemiplegia, and bowel incontinence had a care plan and Kardex requiring bilateral fall mats, staff x2 assistance for bed mobility and toilet use, and incontinence checks and care at least every two hours with moisture barrier. On the survey day, the resident was observed in bed on a scoop mattress with no fall mats in place, and later found in a soiled, wet brief containing a bowel movement, despite multiple CNAs reporting they had not checked or changed the resident since the start of their shifts. The assigned CNA changed the resident alone, initially believed the resident was a one-person assist, and only after reviewing the Kardex acknowledged the two-person assist requirement and two-hour check schedule, while the fall mat was found stored in the closet and nursing leadership acknowledged the care plan had not been updated or fully reviewed.
Unclean Resident Room Floors: A resident room had a large sticky red spill left by the bed over multiple days, and another resident room had a brown thick liquid substance on the floor near the bed. The residents involved had significant medical needs, including dysphagia, epilepsy, gastrostomy/colostomy status, and impaired decision-making in one case. Interviews with CNA, HSKP, a family member, the resident, and the ADMN confirmed housekeeping was responsible for room cleanliness and that spills had remained visible for an extended period.
A resident with cognitive impairment and multiple medical conditions did not receive required mouth care during morning ADL assistance. The resident reported her teeth were not brushed, and staff interviews confirmed oral care was omitted during the morning routine, despite care plan and facility policy requirements.
A resident with a PICC line for IV therapy did not have her dressing changed weekly as ordered, placing her at risk of infection. The facility's records indicated the dressing was changed, but observations showed it was overdue. Interviews with staff revealed uncertainty about the dressing change, and the DON confirmed the oversight. The facility's policies emphasize the importance of following physician orders to prevent complications.
The facility failed to provide adequate care for residents with pressure ulcers, leading to worsening conditions and new ulcers. A resident did not receive daily wound care, and there were delays in receiving biopsy results and starting antibiotics for infections. Another resident developed a Stage 3 ulcer while at the facility, and daily wound care was not consistently provided. A third resident's sacrum ulcer worsened due to lack of care and repositioning. The facility lacked a dedicated wound care nurse, contributing to these deficiencies.
The facility failed to maintain professional standards for food service safety, as observed in their kitchen. The refrigerator temperature log was not filled out for several days, and an expired box of thickener was found in the pantry. The Dietary Manager cited short staffing as a reason for the oversight in temperature logging and was unaware of the expired item. These deficiencies could risk food contamination and foodborne illnesses.
The facility failed to update PASRR screenings for three residents with serious mental disorders, leading to inaccurate assessments and potential lack of specialized services. A resident with bipolar disorder, another with major depressive disorder with psychotic symptoms, and a third with schizoaffective disorder had outdated or incorrect PASRR Level I screenings, despite confirmed diagnoses. The MDS Coordinator acknowledged the inaccuracies, and the administrator expected accurate and updated screenings.
A resident with severe cognitive impairment experienced tooth pain, but the LTC facility failed to ensure timely dental care. Despite complaints from the resident and her family, the nursing staff did not report the issue or place the resident on the dental list. The facility's policy for notifying social services of dental needs was not followed, resulting in delayed treatment and identification of an infection.
A resident with severe cognitive impairment and mobility issues fell during a Hoyer lift transfer when a CNA operated the lift alone, contrary to the facility's two-person assistance policy. This resulted in the resident sustaining a head abrasion and a foot fracture. Witness statements and staff interviews confirmed the failure to adhere to safety protocols, despite previous training on safe patient handling.
A resident with a PEG tube was not provided care in accordance with enhanced barrier precautions, as LVN A failed to wear a gown while administering medications and handling the feeding tube. Despite clear instructions and signage, LVN A only wore gloves and an N95 mask, indicating a misunderstanding of the protocol. The ADON confirmed the need for gown and glove use for residents with internal devices, highlighting a lapse in infection control practices.
A long-term care facility failed to maintain an effective pest control program, resulting in gnats and flies in the rooms of three residents. One resident, with severe cognitive impairment and physical limitations, was uncomfortable with gnats landing on him. Another resident, also with severe cognitive impairment, expressed dissatisfaction with the unresolved pest issue. A third resident, with moderate cognitive impairment, kept a fly swatter nearby to manage flies. Facility staff were aware of the issue, but the monthly pest control service was insufficient to address the problem.
Dirty Privacy Curtain and Stained Bed Linen
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 21 resident rooms reviewed. Resident #39, who had a history of stroke, contractures, hemiplegia, diabetes, and peripheral vascular disease, was assessed as having a BIMS score of 8 out of 15, required substantial assistance with all ADLs, and was frequently incontinent of bowel and bladder. Observation of the privacy curtain in this resident’s room showed multiple large orange-brown stains, and the resident stated the curtain was dirty and needed to be changed. CNA V also stated the curtain had stains and should be clean, and the Housekeeping Supervisor stated it had multiple yellow/orange stains and should be changed out because it was an infection control issue. Resident #28, who had diagnoses including dementia, depression, anxiety, gastrostomy status, colostomy status, stroke, hemiplegia, and pressure ulcers, had a BIMS score of 3 out of 15 and required maximum assistance from staff for all ADLs. Observation of an unoccupied bed in the resident’s room showed a white bedspread with multiple brown and black stains. The Housekeeping Supervisor stated the blanket should have never made it onto the clean linen cart and should not have been used to make up the bed because it did not look clean and would leave a bad impression. The Administrator stated she expected linen and privacy curtains to be in good repair and to be clean, free of odors and stains.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors identified a 19% medication error rate, based on 5 errors out of 26 opportunities, involving 2 of 6 residents and 2 of 4 staff observed during medication administration. The deficiency was based on observation, interview, and record review of medication passes for two residents. For one resident with type 2 diabetes, hyperglycemia, malnutrition, and severe cognitive impairment, the MAR showed Humalog Kwikpen sliding-scale insulin ordered twice daily. During observation, an LVN checked the resident’s blood sugar at 11:01 a.m., reviewed the paper order sheet rather than the electronic MAR, and administered 15 units of insulin lispro when the blood sugar was 463. The LVN stated she had already given insulin earlier that morning when the blood sugar was 383 and said nurses rechecked blood sugar around lunch if it was over 250 in the morning. She also stated she should have called the NP first because there was no order to check blood sugar or give insulin at that time. For another resident with dementia, gastrostomy status, hypotension, anxiety, and epilepsy, the orders required flushing the enteral tube with at least 10 mL of water between each medication. During observation, an LVN administered gabapentin, midodrine, lorazepam, and valproate via the g-tube without flushing between doses, then flushed the tube with 30 mL of water after the last medication. The LVN stated she forgot the water flush between medications and did not realize the order until after the pass. The interim DON stated medications should be given per order, staff should review the physician order from the eMAR, and g-tube medications should be flushed per MD order.
Care Plan Missing Interventions for Hand Contracture
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with multiple sclerosis, tremor, muscle weakness, lack of coordination, mild cognitive impairment, and muscle spasm. The resident’s record showed a left-hand contracture, and the MDS quarterly assessment documented moderately impaired cognition and impairment of one upper extremity. The care plan dated 08/20/2024 did not identify interventions for the contracted left hand. Observation and interview on 02/25/2026 found the resident lying in bed with a left-hand contracture and no brace in place. The resident stated he sometimes had pain in his left hand and was unable to fully open it. He also stated he was not receiving therapy at that time and began to dose off. Interviews with facility staff showed awareness that the contracture should have been addressed in the care plan, but the concern had not been incorporated into the documented plan of care. The DOR stated the resident was being trialed with a splint for one hour daily and had recently been placed on therapy case load three times a week for the hand contracture. The MDS RN, ADMN, Interim DON, and ADON each described the expectation that changes in condition be communicated and reflected in the care plan, and the facility policy stated that if a significant change occurs and the resident remains in the facility, the care plan is to be updated accordingly.
Resident’s Face Contacted Nightstand During Incontinent Care
Penalty
Summary
The facility failed to ensure Resident #71’s environment remained free of accident hazards and that she received adequate supervision during incontinent care. Resident #71 was a female with diagnoses including Type 2 diabetes, hypermetropia, age-related nuclear cataract, dementia, major depressive disorder, anxiety disorder, heart failure, and edema. Her care plan identified her as at risk for falls due to impaired cognition, confusion, gait and balance problems, incontinence, and functional quadriplegia, and she was documented as always incontinent of bowel and bladder and dependent for toileting hygiene and transfers. Resident #71 stated that during incontinent care, her face was pressed against the nightstand when CNA JK turned her over, and she reported discomfort to the right side of her jaw. CNA JK stated that she and another CNA were providing incontinent care and that the resident’s face was placed on the nightstand, though she said the resident did not complain of pain. CNA JL stated she assisted with the care and observed the resident’s face close to the nightstand, but said it did not touch it and the resident did not complain of pain. The former DON stated the resident later implied that CNA JK had turned her over and her face touched the nightstand, and she assessed the resident’s face but did not observe pain or swelling. She also stated the resident later could not wear her dentures due to swelling to the right side of her face, and an x-ray was obtained that showed no acute fracture or dislocation. The facility’s resident rights policy stated residents have a right to a safe, clean, comfortable, and homelike environment, including receiving treatment and supports for daily living safely. The Administrator stated the facility did not have a policy for accidents/supervision.
Oxygen Not Set Per Physician Order
Penalty
Summary
Resident #6, who had diagnoses including chronic respiratory failure with hypoxia, Alzheimer's disease, bipolar disorder, shortness of breath, and progressive supranuclear ophthalmoplegia, had a physician order for oxygen at 3 L/min via nasal cannula every shift. The resident's MDS indicated moderate cognitive impairment and that she was receiving oxygen therapy, and her care plan included oxygen therapy with the goal of having no signs or symptoms of poor oxygen absorption. Physician progress notes also documented severe restrictive lung disease and continued supplemental oxygen for comfort and respiratory status monitoring due to hospice status. During observation, Resident #6 was found receiving oxygen via nasal cannula with the concentrator set at 4 L/min instead of the ordered 3 L/min. On a later observation, the nasal cannula was not on the resident's face and was draped over the bedside table out of reach, while the concentrator remained set at 4 L/min. The resident stated the oxygen helped her breathing and that she sometimes removed the cannula because it hurt the back of her ears. The LVN stated the resident sometimes took off the cannula due to ear pain, that he was responsible for ensuring the oxygen was set correctly per physician orders, and that he reduced the setting from 4 L/min to 3 L/min after being questioned. The Interim DON stated it was the nurse's responsibility to ensure oxygen was set correctly by physician orders and to monitor settings every shift.
Failure to Provide and Accurately Document Ordered Splint Therapy for Contractures
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered splint therapy and appropriate services to maintain or improve range of motion (ROM) for a resident with significant contractures and hemiplegia. The resident, an older male admitted with diagnoses including cerebral infarction, left knee contracture, hemiplegia of the left nondominant side, and cognitive communication deficit, had a quarterly MDS showing moderate cognitive impairment and impaired ROM in upper and lower extremities on one side. His care plan identified altered musculoskeletal status related to contractures of the left hand and left knee, with interventions to encourage, supervise, and assist with use of supportive devices (splints) as recommended, and to monitor the left hand and left knee splint/carrot daily and wear as tolerated. Physician orders directed that a left knee splint be donned and doffed every day shift for up to 4 hours daily or as tolerated, and that a left hand orthotic be applied daily for 4 hours or as tolerated, with monitoring for skin issues. The MAR for January documented that both the left knee splint and left hand orthotic were administered every day from the 1st through the 27th, with repeated entries by one LVN indicating they were applied. However, on the survey date, observations showed the resident lying on his right side with contracted lower extremities and no leg splint in place, and later observation confirmed there was no splint on his left hand. The resident’s family member reported that his legs were restricted from the knee and that this was not his condition on admission, and stated that staff did not rotate him. Interviews with staff revealed that the ordered splints were not being consistently applied despite documentation indicating otherwise. The Director of Rehabilitation reported that PT had previously worked on passive ROM and issued a left knee splint, and OT had supplied a left-hand carrot, but therapy services had ended months earlier. One LVN stated he was responsible for applying the splints on day shift, acknowledged he had not seen the hand splint for weeks and could not find it after a room change, and estimated he had not applied the leg splint since the prior year. He admitted sometimes forgetting the splints and confirmed he had signed in the computer that the splints were applied when they were not. Other staff, including another LVN and CNAs, either could not recall the last time they applied the splints or reported they had not seen the splints in use recently. The facility’s policy on immobilization devices and splints required review of physician orders and documentation of all care and the resident’s response, which was not followed in practice for this resident’s splint use.
Failure to Implement Care-Plan Interventions for Fall Prevention, Assistance Level, and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a male resident with a history of cerebral infarction, left knee contracture, hemiplegia of the left nondominant side, need for assistance with personal care, and cognitive communication deficit. His quarterly MDS showed a BIMS score of 8/15, indicating moderate cognitive impairment, and documented that he required substantial/maximal assistance with toileting hygiene and rolling. His care plan and Kardex identified him as at risk for falls due to hypertension and a prior fall, with interventions including bilateral fall mats at both sides of the bed, staff x2 assistance for bed mobility and toilet use, and bowel incontinence management with checks every two hours and assistance with toileting as needed. On the survey date, observation at 10:09 a.m. showed the resident lying on a scoop mattress with no fall mats on either side of the bed, despite the care plan and Kardex specifying bilateral fall mats. Later observation at 11:07 a.m. revealed the resident’s brief was soiled and the blue line indicator showed it was wet, although the resident denied feeling wet. Multiple CNAs interviewed between approximately 11:15 a.m. and 11:45 a.m. reported they had not checked or changed the resident since the start of their shifts at 6:00 a.m., and one CNA assigned to the resident stated she arrived late and had not been in the resident’s room prior to the surveyor’s observation. The assigned CNA subsequently changed the resident’s soiled brief alone at 11:25 a.m., and the soiled brief contained a bowel movement. Further interviews and record review showed that the Kardex required staff x2 for bed mobility and toilet use, and incontinent care at least every two hours with application of moisture barrier after each episode. The assigned CNA initially stated the resident was a one-person assist for incontinent care and was unsure what the Kardex indicated, then acknowledged after review that the resident required two-person assistance and that she was supposed to check and change him every two hours. She reported last changing him at 11:00 a.m. and stated she had never seen a fall mat at the bedside. Observation confirmed the fall mat was stored in the resident’s closet. Nursing leadership and other staff acknowledged that the care plan had not been updated to reflect changes such as the use of a scoop mattress and that the resident’s care plan had not yet been reviewed for personalization, resulting in care that did not follow the documented interventions for fall prevention, assistance level, and incontinence management.
Unclean Resident Room Floors
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms by leaving floor spills and stains in place in two resident rooms over multiple days. In one room, a large sticky red substance/spill was observed on the right side of the resident’s bed on 09/15/2025, again on 09/16/2025, and later a plastic cup with a red juice-like substance was seen on the bedside tray table with a slight red substance on the floor as if it had been partially cleaned up. In another room, a brown thick liquid substance was observed on the right side of the bed on 09/18/2025. Resident #2 was a male admitted on 03/20/2025 with diagnoses including other lack of coordination, need assistance with personal care, epilepsy, GERD, and dysphagia; his quarterly MDS showed a BIMS of 10 and no cognitive patterns affecting daily decisions. Resident #7 was a female admitted on 07/18/2025 with diagnoses including gastrostomy status, colostomy status, muscle wasting and atrophy of the left lower leg, epilepsy, and dysphagia; her quarterly MDS did not reveal a BIMS and stated she could not make decisions on her own and was severely impaired. Interviews with CNA P, HSKP G, the resident’s family member, Resident #7, and the ADMN confirmed that housekeeping was responsible for room cleanliness, that spills could remain for some time, and that staff expected rooms and floors to be kept clean.
Failure to Provide Required Oral Care During Morning ADL Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living (ADLs), specifically personal hygiene and oral care, did not receive mouth care as required by her care plan. The resident, an elderly female with diagnoses including Alzheimer's disease, muscle weakness, lack of coordination, hypertension, constipation, hyperlipidemia, anemia, and dementia, was assessed as needing supervision or touching assistance with personal hygiene. On the morning in question, observation revealed the resident was clean and dressed, but during an interview, she reported that her teeth had not been brushed that morning, although her hair had been brushed. Further investigation through interviews with the CNA and LVN confirmed that oral care was not provided during the initial morning care routine. The CNA stated she had not brushed the resident's teeth and was unsure if the hospice aide had done so. The facility's policy and the resident's care plan both required assistance with oral hygiene, but this was not carried out as expected. The DON confirmed that staff were responsible for providing ADL care, including oral care, and that training was provided regularly.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids for a resident, specifically regarding the timely changing of a PICC line dressing. The resident, an elderly female with a history of sepsis, urinary tract infection, dysphagia, and mild cognitive impairment, had a physician's order to have her PICC line dressing changed weekly. However, upon observation, it was found that the dressing had not been changed since 01/06/2025, despite the treatment administration record (TAR) indicating it was changed on 01/13/2025. Interviews with the nursing staff, including the Licensed Vocational Nurse (LVN) responsible for the dressing change, revealed uncertainty about whether the dressing was changed as ordered. The LVN acknowledged that the dressing should have been changed weekly for hygiene reasons and to prevent infection. The Director of Nursing (DON) confirmed that the dressing was overdue for a change and that the staff was responsible for ensuring compliance with physician orders. The facility's policy on medication administration and IV dressing changes emphasized the importance of following physician orders and documenting medication administration accurately. The failure to change the dressing as ordered placed the resident at risk of infection, as the dressing was impregnated with an antiseptic to prevent bacterial growth. The oversight was identified during a survey, highlighting a deficiency in the facility's adherence to professional standards of practice.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, leading to worsening conditions and the development of new ulcers. Resident #43 did not receive daily wound care on multiple occasions, and there was a significant delay in receiving biopsy results and starting antibiotics for MRSA and osteomyelitis. The resident's wounds were not measured throughout October, and the Wound Care MD did not see the resident after early October due to staffing issues. Additionally, the facility did not have a dedicated wound care nurse, which contributed to the lapses in care. Resident #45 developed a Stage 3 pressure ulcer on the toe while at the facility, which was not present on admission. The facility failed to provide daily wound care on several dates, and the resident was observed without pressure-relieving boots on multiple occasions. The facility's records showed inconsistencies in wound care documentation, and the resident's condition was not adequately monitored or addressed. Resident #7 also experienced a lack of daily wound care, resulting in the worsening of a sacrum pressure ulcer. The resident was bedbound and dependent on staff for all activities of daily living, yet the facility failed to reposition her regularly or get her out of bed. The facility's policy on pressure injury prevention and treatment was not followed, leading to inadequate care and monitoring of the resident's pressure ulcers.
Removal Plan
- A head-to-toe assessment was completed on resident #43 by the DON and Regional Compliance Nurse. No additional pressure wounds were identified.
- All of resident #43's wounds were measured by the DON and Regional Compliance Nurse. The MD was notified of all changes in measurements by the Regional Compliance. All measurements were documented in the chart by the Regional Compliance nurse.
- Resident #43's antibiotic medication was initiated by the charge nurse.
- The Administrator has designated that the ADON will round with the wound care MD. In the event the ADON is unavailable the designated nurse for the resident will round with the MD.
- The Administrator has designated that the ADON (LVN) will measure all resident wounds in the facility and document findings in the resident's chart. Wound assessments will be completed weekly. DON/Weekend RN will oversee the ADON (LVN) /Charge Nurse to ensure wound measurements and treatments have been completed.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, which was the only one reviewed for dietary services. During an observation, it was noted that the refrigerator temperature log had not been filled out since a specified date, indicating a lapse in daily monitoring. The Dietary Manager acknowledged that the logs should be checked daily but attributed the oversight to being short-staffed. Additionally, an expired box of thickener was found in the pantry, which the Dietary Manager was unaware of. She mentioned that they had switched to a new brand and assured that none of the residents had received the expired product. The facility's policies on storage refrigerators and food safety, both dated 2012, were reviewed. The Storage Refrigerators policy mandates that temperatures be frequently monitored and recorded during both the am and pm shifts, with specific temperature requirements for refrigerators and freezers. The Food Safety policy requires that food be properly wrapped, labeled, and stored, with perishable foods used within seven days and non-perishable foods used as long as quality is maintained. The presence of expired items and the failure to log refrigerator temperatures as per policy could potentially place residents at risk for food contamination and foodborne illnesses.
Failure to Update PASRR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to refer three residents with newly evident or possible serious mental disorders for a Level II PASRR review, which is necessary to ensure they receive appropriate specialized services. Resident #14, a male with bipolar disorder and major depressive disorder, had a PASRR Level I screening that inaccurately indicated no mental illness. Despite a psychiatric assessment confirming bipolar disorder, no new PASRR was completed after the diagnosis. Resident #26, a male with major depressive disorder with psychotic symptoms and anxiety disorder, also had a PASRR Level I screening that incorrectly showed no mental illness. A psychiatric assessment later confirmed his mental health conditions, but a new PASRR was not conducted. The resident was on medications for his conditions, yet the PASRR screening remained outdated. Resident #36, a female with schizoaffective disorder and schizophrenia, had a PASRR Level I screening that incorrectly listed dementia as the primary diagnosis and did not acknowledge her mental illness. The MDS Coordinator admitted to entering inaccurate information from a previous facility's screening. The facility's administrator expected PASRR screenings to be accurate and updated with new diagnoses, but this was not done, potentially affecting the residents' access to necessary services.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining routine and 24-hour emergency dental care, which was identified during a survey. The resident, who had severe cognitive impairment and required assistance with activities of daily living, complained of tooth pain. Despite this, the facility did not ensure the resident was referred to a dentist promptly. The resident's family member also expressed concerns about the need for dental care, but the facility's response was inadequate, as the resident continued to experience tooth pain and was not placed on the dental list for evaluation. The resident's complaints of tooth pain were not consistently reported or acted upon by the nursing staff. One nurse administered pain medication but did not report the issue to the social worker or medical director, as it was considered a one-time event. Another nurse was aware of the resident's toothache but did not take further action due to the social worker's absence. The facility's policy required the Director of Nursing Services or designee to notify social services of a resident's need for dental services, but this protocol was not followed. The facility's failure to address the resident's dental needs resulted in a delay in treatment, which was only initiated after the surveyor's intervention. The resident was eventually sent for a dental appointment, where an infection was identified, and treatment was prescribed. The lack of timely dental care could have led to further health complications for the resident, highlighting a deficiency in the facility's adherence to its dental services policy.
Resident Injury Due to Improper Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment for Resident #2, who experienced a fall during a Hoyer lift transfer. The incident occurred when CNA K operated the Hoyer lift alone, contrary to the requirement for two-person assistance. This resulted in Resident #2 sustaining a head abrasion and a left foot fracture. The resident, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, was at risk for injury due to her medical conditions, including vascular dementia and hemiplegia. The incident was documented in various records, including witness statements from CNAs involved. CNA K attempted to transfer the resident with the Hoyer lift while CNA J stepped out to retrieve a wheelchair. During this time, the resident slipped from the Hoyer pad, leading to the fall. CNA J noted that one of the loops on the Hoyer strap might not have been secured correctly, which could have been identified if both CNAs were present during the transfer. Interviews with staff, including the ADON and the Administrator, confirmed that the facility's policy required two staff members to be present during Hoyer lift transfers to prevent accidents. Despite previous in-service training on safe patient handling and transfer procedures, the failure to adhere to these protocols resulted in the incident. The facility's hydraulic lift policy also emphasized the need for adequate staff involvement to ensure resident safety during transfers.
Inadequate Adherence to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A, who did not adhere to the required enhanced barrier precautions while providing care to a resident with a PEG tube. The resident, a male with a history of metabolic encephalopathy, seizures, hypertension, and an open neck wound, was on enhanced barrier precautions due to the presence of a feeding tube. Despite the clear instructions on the resident's care plan and the signage at the resident's doorway, LVN A did not wear a gown while administering medications and replacing the feeding bottle, only wearing gloves and an N95 mask. Interviews with LVN A and the ADON revealed a lack of understanding and adherence to the enhanced barrier precautions protocol. LVN A admitted to not wearing a gown because he believed it was only necessary for residents with multidrug-resistant organisms, indicating a gap in training or comprehension. The ADON confirmed that residents with internal devices like a g-tube should be on enhanced barrier precautions, which include wearing a gown and gloves. The facility's policy on enhanced barrier precautions was not followed, potentially risking the transmission of infections.
Deficient Pest Control Program in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of gnats and flies in the rooms of three residents. Resident #1, a male with severe cognitive impairment and multiple physical limitations due to burns, was observed with gnats flying around his face and room. He expressed discomfort from the gnats landing on him. Resident #2, a female with severe cognitive impairment and communication issues, also had gnats in her room and expressed dissatisfaction with the unresolved pest problem. Resident #3, a female with moderate cognitive impairment, was observed with a fly on her walker and kept a fly swatter nearby to manage the pests. Interviews with facility staff, including the Administrator and the DON, revealed awareness of the pest issue. The Administrator acknowledged the presence of gnats and flies and mentioned that the facility relied on monthly pest control services, which he believed addressed the issue. However, he was uncertain about the risks posed to residents by the pests. The DON confirmed that some residents had insects in their rooms and highlighted the potential risk of bites and infection, particularly for residents like Resident #1, who could not swat away insects. The facility's pest control policy outlined procedures for maintaining an insect and vermin-free environment, including regular spraying and structural maintenance to prevent pest entry. However, a review of the facility's pest control service notification for May 2024 indicated that issues with flies, fruit flies, and ants persisted, particularly in the rooms of Residents #1 and #2. This deficiency in pest control could place residents at risk of residing in an environment with pests.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 591 citations issued within 25 miles in the last 12 months — including the 47 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Humble
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Humble | 1 mi | ★★★★★ | 1 | 0 |
| Park Manor Of Humble | 1.7 mi | ★★★★★ | 9 | 0 |
| Crimson Heights Health & Wellness | 1.8 mi | ★★★★★ | 15 | 0 |
| Deerbrook Skilled Nursing And Rehab Center | 2.2 mi | ★★★★★ | 14 | 3 |
| Fall Creek Rehabilitation And Healthcare Center | 3.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oakmont Healthcare And Rehabilitation Of Humble.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.