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 Park Manor Of Westchase during CMS and state inspections, most recent first.
A resident with vascular dementia and moderate cognitive impairment, who required assistance with ADLs and had an order to go out on pass with medications, was not identified in the care plan as an elopement risk and was known by the DON to be noncompliant with sign-in/sign-out procedures. On an evening when the front desk was not staffed past the receptionist’s 5 p.m. departure, the resident was last seen in his room around the early evening and received medications around 7 p.m., but staff later found his room empty and could not locate him in the building. There was no record of him signing out, and the DON reported there was no policy on rounding frequency while also acknowledging that residents could leave during pass hours and that the facility was responsible for accounting for them. Around the same time, a separate resident emergency prompted a 911 response and the front door being held open, during which the DON’s root cause analysis concluded the resident likely exited unnoticed; he was later found several miles away in a parking lot with injuries requiring hospital care.
A resident admitted with a pressure ulcer and complex medical conditions did not have a baseline care plan developed within 48 hours to address the wound, despite documentation and staff awareness of its presence. The initial care plan instead focused on a resolved UTI, and confusion among staff regarding care plan responsibilities led to the omission of wound care interventions in the resident's plan.
A resident with significant medical conditions left the facility on pass and did not return, leading to an Immediate Jeopardy deficiency. The facility failed to monitor the resident's return or take appropriate action when he did not come back, exposing residents to potential harm. Staff interviews revealed a lack of follow-up and inadequate implementation of policies for residents going out on pass.
The facility failed to transmit completed Discharge MDS assessments for two residents within the required 14-day period after completion. The residents involved had conditions such as heart failure and epilepsy. Interviews with staff revealed that the assessments were missed despite the facility's policy to transmit them weekly, resulting in non-compliance with regulations.
The facility failed to label and date opened medications in accordance with professional principles, as observed in several medication carts. Opened medications such as eyedrops, ointments, nasal sprays, and inhalation powders were not labeled with the resident's name or dated, potentially risking adverse reactions. Interviews revealed a lack of awareness among staff, and the facility's policy did not address this requirement.
The facility failed to maintain proper infection control practices, as CNAs did not follow hand hygiene protocols and PPE usage during resident care. A CNA did not wash hands between glove changes for a resident with a Foley catheter, while another CNA failed to secure a catheter properly and did not perform hand hygiene. Additionally, a CNA did not wear a protective gown for a resident in enhanced barrier precautions. These actions were recognized as infection control issues by the facility's staff.
A resident with severe cognitive impairment was wheeled into the dining room with an exposed catheter bag, compromising their dignity and privacy. The resident, wearing shorts, had no privacy cover for the catheter bag, which was against the facility's policy. Staff interviews confirmed awareness of the dignity issue, but an oversight occurred due to a distraction with another resident.
A resident with chronic conditions and moderately impaired cognition did not receive necessary assistance with personal hygiene, specifically shaving facial hair, as outlined in her care plan. Despite expressing her desire to be shaved, staff failed to provide this care consistently, leading to a deficiency in the facility's adherence to ADL assistance protocols.
A resident with chronic kidney disease, diabetes, and heart failure received inadequate incontinence and Foley care, leading to a risk of urinary tract infections. A CNA placed the Foley bag on the bed, risking urine backflow, and failed to properly clean the resident, leaving bowel movement residue. Interviews confirmed the CNA did not follow proper procedures, despite having received training.
A resident with a PEG tube was at risk of complications when a CNA failed to pause the G-tube feeding before providing care, leaving the bed flat during the process. The resident, with severe cognitive impairment, required the head of the bed to be elevated during feeding to prevent aspiration. Despite training, the CNA forgot to inform the nurse to pause the feeding, contrary to facility protocol.
A resident with severe cognitive impairment and multiple health issues was not provided oxygen therapy according to physician orders, with the concentrator set at 3.5L instead of the prescribed 3L. Staff interviews revealed a lack of awareness and communication about the correct oxygen settings, and the facility's policy on oxygen administration was not provided upon request.
A resident with multiple medical conditions did not receive proper incontinent care, as a CNA failed to follow infection control protocols by not wearing a gown and not sanitizing hands between glove changes. The DON confirmed that these actions could lead to infections, highlighting a deficiency in the facility's adherence to its infection control policies.
A CNA and an LVN at an LTC facility failed to adhere to infection control protocols, including not sanitizing hands between glove changes and not properly donning and doffing PPE. These actions occurred during care for residents with severe cognitive impairments and multiple medical conditions, placing them at risk for infections.
The facility failed to provide a safe, clean, and sanitary environment for two residents. One resident's restroom had feces on the wall and in the commode, while another resident's room had dried urine beneath the bed. Both residents require assistance for toileting and other activities of daily living. The facility's policies for cleaning were not followed, leading to unsanitary conditions.
Elopement of Cognitively Impaired Resident During Unmonitored Exit Opportunity
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one cognitively impaired resident. The resident was an older male with vascular dementia and a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. His MDS indicated no documented wandering or behavioral issues and a need for partial/moderate assistance with transfers and ADLs. His comprehensive care plan, initiated several days before the incident, did not identify him as an elopement risk. A physician order allowed him to go out on pass with medications, and the DON stated that residents and responsible parties were educated on admission that residents were to sign out when leaving on a pass, but the DON also acknowledged that this resident was not compliant with signing in and out. On the evening of the incident, the resident was last clearly observed by staff between approximately 5:00 p.m. and 7:00 p.m. CNA E reported assisting him to the dining room for breakfast and lunch and later seeing him seated in a chair in his room around 6:30–7:00 p.m. while providing care to his roommate. CMA A documented administering his evening medications at approximately 7:18 p.m. and then continued her medication pass and responded to other residents’ needs. At some point after this, CNA E returned to the room and found that the resident was no longer present, and she notified other staff. Nurse A, who was familiar with the resident but not his primary nurse, recalled seeing him sometime after dinner between 5:00 p.m. and 6:00 p.m. and stated that an elopement code was implemented around 8:00 p.m. after staff notified her that the resident was missing. The receptionist, whose shift that day ended at 5:00 p.m., stated that front door coverage was expected until 8:00 p.m. and that the front desk was not to be left unattended, but she was not present at the time the resident went missing. The DON and other records indicated that the resident did not sign out and there was no entry for him on the facility’s entrance and exit log on the date of the incident. The DON stated that there was no policy specifying how frequently staff should round on residents and that residents had the right to leave during identified pass hours, while the facility remained responsible for their safety and accounting for their whereabouts. The DON also reported that staff were aware the resident was not compliant with sign-in/sign-out procedures. Around the time the resident was discovered missing, another resident-related emergency occurred that required a 911 call and the presence of first responders, during which the facility’s front door was held open as another resident was prepared for transport. Based on the facility’s root cause analysis, the DON stated it was likely that the missing resident exited the building during this emergency response. The resident was later found approximately seven miles from the facility in the parking lot of a local emergency care center with a laceration to his right eye and minor injuries to his hands, and he required hospitalization for evaluation and treatment. Hospital records documented that the resident was brought to the emergency department by a local unhoused person who found him in the parking lot. On arrival, he was cold, bleeding from his right scalp, and had minor lacerations to both hands. A CT of the head showed right periorbital soft tissue swelling consistent with trauma from a fall, and he was found to be dehydrated, requiring hypotonic saline. The ED physician obtained history from the nursing facility and the resident’s family, noting that he had been placed in the facility due to difficulties with ambulation but was able to ambulate with a walker at admission. Facility documentation and interviews confirmed that staff did not witness his exit, that he was not accounted for through the sign-out process, and that he was ultimately reported missing to police later that evening, after which he was located offsite and transferred to the hospital.
Failure to Develop Timely Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with multiple complex medical conditions, including a pressure ulcer. Despite documentation from hospital records and physician notes indicating the presence of a pressure ulcer on the left lateral thigh or buttock at the time of admission, the resident's initial care plan did not address this wound. Instead, the care plan focused on a urinary tract infection (UTI), which, according to staff interviews and the Director of Nursing, had already resolved prior to admission. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for care plan development. The MDS nurse, wound care nurse, and other nursing staff each believed that another team member was responsible for including wound care in the resident's care plan. The wound care nurse stated that interventions for the pressure ulcer were implemented and that education was provided to the resident, but these interventions were not reflected in the baseline care plan. The MDS assessment did document the presence of a pressure ulcer, but this information was not translated into the care plan within the required timeframe. Facility policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, including measurable objectives and timeframes to address identified problems. However, the resident's care plan did not include any mention of the pressure ulcer or related interventions, despite clear evidence from medical records and staff interviews that the wound was present and required ongoing care. This failure to develop and implement an appropriate care plan within 48 hours of admission resulted in a deficiency, as the resident's immediate needs were not formally addressed according to professional standards of care.
Resident Left Facility Unsupervised and Did Not Return
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision, as evidenced by the case of a resident who left the facility on pass and did not return. The resident, who had a history of cerebral infarction, traumatic subdural hemorrhage, and other significant medical conditions, was cognitively intact with a BIMS score of 15. Despite his medical history, the facility did not make attempts to locate him after he left, and he was later admitted to the hospital with a stroke. Interviews with facility staff revealed that the resident frequently left the facility on pass and was expected to return. However, on the day in question, staff did not adequately monitor his return or take immediate action when he did not come back. The facility's policy required residents to sign out and in, but there was a lack of follow-up when the resident did not return, and the facility did not notify law enforcement or emergency services promptly. The deficiency was identified as an Immediate Jeopardy due to the potential harm to residents from inadequate supervision. The facility's failure to monitor the resident's return and to follow up appropriately when he did not return exposed residents to potential harm, injury, or death. The facility's policies and procedures for residents going out on pass were not effectively implemented, leading to this serious oversight.
Failure to Transmit Discharge MDS Assessments Timely
Penalty
Summary
The facility failed to transmit completed Discharge Minimum Data Set (MDS) assessments for two residents within the required 14-day period after completion. This deficiency was identified during a record review and interviews with facility staff. The residents involved were a male with acute on chronic systolic heart failure and gait abnormalities, and another male with a traumatic subdural hemorrhage and epilepsy. Both residents had their discharge MDS assessments completed but not transmitted to the Centers for Medicare & Medicaid Services (CMS) as required. Interviews with the MDS Coordinator and the Administrator revealed that the facility uses the Resident Assessment Instrument (RAI) Manual for guidance and that the assessments should have been transmitted within the stipulated timeframe. The MDS Coordinator acknowledged the oversight and mentioned that the facility transmits assessments weekly, but these particular assessments were missed. The Administrator confirmed that the failure to transmit the assessments was against the facility's policy and resulted in non-compliance with regulations.
Failure to Label and Date Opened Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles, including the appropriate accessory and cautionary instructions and expiration dates. During observations, it was found that several medication carts contained opened medications such as eyedrops, ointments, nasal sprays, and inhalation powders that were not labeled with the resident's name or dated. This was observed in the medication carts shared between halls 100 and 400, and halls 200 and 300. Interviews with the LVNs and MA involved revealed a lack of awareness regarding the importance of dating medications upon opening to ensure their effectiveness and safety. The Director of Nursing (DON) was interviewed and expressed uncertainty about the requirement to label and date opened medications, despite a recent visit from the facility's pharmacist who reportedly found everything in order. The facility's policy on medication storage, last revised in April 2007, did not address the labeling and dating of medications when opened. This oversight could potentially place residents at risk of adverse medication reactions and infections, as the medications may not be effective if used beyond their recommended period after opening.
Inadequate Infection Control Practices in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and personal protective equipment (PPE) usage by certified nursing assistants (CNAs) during resident care. For Resident #31, CNA C did not follow proper hand hygiene protocols during Foley and incontinent care, changing gloves multiple times without washing or sanitizing hands, and placing a trash bag on a clean field, leading to potential cross-contamination. This was acknowledged by CNA C, the Infection Preventionist (IP), the Director of Nursing (DON), and the Administrator, all of whom recognized the actions as infection control issues. Resident #41 also experienced inadequate infection control practices. CNA AA failed to perform appropriate hand hygiene during Foley catheter and incontinent care, using the same gloves for multiple tasks and not cleaning the catheter in a circular motion. Additionally, the catheter was not secured properly, posing a risk of obstruction. CNA AA admitted to being nervous and forgetting to change gloves, which could lead to cross-contamination. The DON confirmed the necessity of proper hand hygiene between glove changes to prevent infection. For Resident #76, CNA F did not wear a protective gown while providing incontinent care in an enhanced barrier precaution room, which was necessary to prevent cross-contamination due to the resident's G-tube and wound. This oversight was observed by LVN S, who intervened by providing a gown to CNA F. Both the DON and the Administrator acknowledged the importance of wearing PPE in such situations to prevent the spread of infections.
Resident Dignity Compromised by Exposed Catheter Bag
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident #44, by allowing the resident's catheter bag to be exposed in a public area. Resident #44, a male with severe cognitive impairment and multiple medical conditions including Alzheimer's Disease, was observed being wheeled into the dining room with his catheter bag visibly strapped to his leg. The resident was wearing shorts, which did not cover the catheter bag, and there was no privacy cover in place. This incident was noted during an observation on February 18, 2025. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Recreational Therapist (RT A), confirmed that the exposure of the catheter bag was a breach of the resident's dignity and privacy. The ADON acknowledged the issue and stated that the resident should have been covered or dressed in long pants. RT A admitted to being aware of the need for privacy and dignity but was distracted by another resident's potential fall, leading to the oversight. The facility's policy on urinary leg drainage bags, which mandates maintaining privacy under resident clothing, was not adhered to in this instance.
Failure to Provide Necessary ADL Assistance for Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident with moderately impaired cognition, chronic kidney disease, diabetes mellitus, and heart failure. The resident required extensive assistance with personal hygiene, including shaving facial hair, which was not provided as needed. Despite the resident expressing a desire to have her facial hair shaved and informing the aides, the staff did not fulfill this request. Observations confirmed the presence of facial hair on the resident's chin, and interviews with staff revealed a lack of adherence to the resident's care plan, which included shaving on shower days and as needed. Interviews with the Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) indicated that the aides were responsible for shaving the resident, but this was not consistently done. The Director of Nursing (DON) and Infection Preventionist (IP) acknowledged that the resident should not have to request shaving as it is part of her ADL care. There was no documentation of the resident refusing to be shaved or preferring her daughter to perform this task. The facility's policy on shaving, intended to promote cleanliness and skin care, was not followed, leading to the deficiency in care for the resident.
Inadequate Incontinence and Foley Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder and had an indwelling catheter, leading to a risk of urinary tract infections. The resident, a female with chronic kidney disease, diabetes mellitus, and heart failure, required extensive assistance with activities of daily living and had moderately impaired cognition. During an observation, a CNA placed the resident's Foley catheter bag on the bed, which was at the same level as the bladder, instead of below it, potentially causing urine backflow and increasing the risk of infection. The CNA also failed to properly clean the resident during incontinence and Foley care. The CNA did not separate the labia or buttocks while cleaning, resulting in residual bowel movement being left on the resident's skin. When instructed to clean the area again, the CNA found bowel movement residue on the wipes, indicating inadequate initial cleaning. The improper cleaning technique, including wiping towards the body instead of away, further increased the risk of infection. Interviews with the CNA, IP, LVN, DON, and Administrator confirmed that the CNA did not follow proper procedures for Foley and incontinence care. The facility's policy required the Foley bag to be positioned below the bladder and the perineal area to be cleaned thoroughly to prevent infection and skin irritation. The CNA acknowledged the training received but did not adhere to the protocols, leading to the deficiency in care for the resident.
Failure to Pause G-Tube Feeding During Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a gastrostomy tube (G-tube), leading to a potential risk of complications. A certified nursing assistant (CNA) did not inform the nurse to pause the G-tube feeding before providing incontinent care to a resident. During the care, the CNA lowered the head of the resident's bed to a flat position while the G-tube feeding continued, contrary to the care plan and physician's orders, which required the head of the bed to be elevated between 30 to 45 degrees during feeding to prevent aspiration. The resident involved was an elderly female with severe cognitive impairment, requiring extensive assistance with activities of daily living (ADL) and had a percutaneous endoscopic gastrostomy (PEG) tube due to dysphagia. The facility's protocol mandated that the feeding be paused during ADL care to prevent aspiration risks. Despite having received training on handling residents with PEG tubes, the CNA forgot to pause the feeding and was unaware of the potential consequences of not doing so. The Director of Nursing (DON) confirmed that the feeding should have been paused to prevent vomiting and abdominal pain.
Failure to Administer Oxygen Therapy as Ordered
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, heart failure, and aphasia, was admitted with severely impaired cognition and required continuous oxygen therapy at 3 liters per minute via nasal cannula, as per physician orders. However, during an observation, it was noted that the oxygen concentrator was set at 3.5 liters per minute, which was not in accordance with the physician's orders. Interviews with staff revealed a lack of awareness and communication regarding the correct oxygen settings for the resident. A CNA and an LVN both confirmed the incorrect setting, and the LVN admitted to not knowing the prescribed oxygen level. The DON stated that the facility follows physician orders and that exceeding the prescribed oxygen could lead to increased CO2 levels and confusion in the resident. Despite the facility's policy requiring nurses to monitor and set oxygen levels correctly, the policy was not provided upon request, indicating a potential gap in policy adherence and documentation.
Inadequate Incontinent Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in infection control protocols. The resident, who was always incontinent and required extensive assistance, did not receive proper care to prevent urinary tract infections. During an observation, a CNA was seen providing care without following infection control protocols, such as not wearing a gown and failing to sanitize hands between glove changes. The resident, who had multiple medical conditions including metabolic encephalopathy, dysphagia, and acute kidney failure, was observed to have bowel movements that were not adequately cleaned. The CNA wiped the resident multiple times without sanitizing hands between glove changes, which is against the facility's infection control policies. The CNA admitted to forgetting to wear PPE and not sanitizing hands due to the absence of sanitizer in the room. The Director of Nursing (DON) confirmed that the staff is expected to don PPE and sanitize hands to prevent the spread of germs. The DON acknowledged that the failure to follow these protocols could lead to infections. The facility's policies on infection control and hand hygiene were not adhered to, as evidenced by the CNA's actions during the care of 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 several observed deficiencies in the care provided to residents. A CNA did not use an alcohol-based sanitizer between changing gloves while providing incontinent care to a resident, which is a critical step in preventing the spread of infections. This resident, who has multiple medical conditions including metabolic encephalopathy and dysphagia, requires extensive assistance with activities and is always incontinent. The CNA's failure to sanitize hands between glove changes was attributed to the absence of sanitizer in the room. Additionally, an LVN did not clean the peri-wound area before applying a dressing during wound care for another resident. This resident has severe cognitive impairment and is dependent on staff for toileting hygiene. The LVN also failed to remove his gown and gloves after leaving the resident's room, re-entering and continuing care with the same contaminated PPE. This practice was repeated with another resident, who also has severe cognitive impairment and is at risk for pressure ulcers. The LVN acknowledged the importance of cleaning the peri-wound to prevent bacteria from entering the wound and admitted to not following proper PPE protocols. Interviews with the DON and ICP revealed that staff were expected to follow specific infection control procedures, including donning and doffing PPE correctly and sanitizing hands between glove changes. The facility's policies on wound care and infection control emphasize the importance of these practices to prevent infections. However, the observed actions of the CNA and LVN indicate a lapse in adherence to these protocols, placing residents at risk of developing infections.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, clean, and sanitary environment for two residents. Resident #2's restroom was observed to have two small brown spots that appeared to be feces near the grab bar on the wall, a commode full of cloudy water with feces remnants, and dried feces particles covering the bowl. Additionally, a trash bag of soiled briefs was found on top of the trash can, and a bed pan was hanging in a clear plastic drawstring bag. Resident #2, who has moderate cognitive impairment and requires assistance for toileting, confirmed that the toilet was backed up and that staff had previously instructed her to use a bed pan to remove water when the toilet backed up. The Central Supply Coordinator confirmed that housekeeping had not yet cleaned the rooms on the 300 hall and that all staff were responsible for reporting maintenance issues. The Administrator and DON were not initially aware of the cleanliness concerns but acknowledged the need for immediate attention to the situation. Resident #4's room was observed to have a large area of dried dark urine beneath the resident's bed. Resident #4, who has severe cognitive impairment and requires maximum assistance for toileting and other activities of daily living, was found in his restroom with the door closed. The Central Supply Coordinator confirmed the substance on the floor was urine and stated she would notify housekeeping for immediate attention. The Administrator and DON were not initially aware of the cleanliness concerns but acknowledged the need for immediate attention to the situation. The facility's policies for bathroom and daily patient room cleaning, revised in 2017, emphasize the importance of proper cleaning to prevent the spread of infection. However, the observations and interviews revealed that the facility failed to adhere to these policies, resulting in unsanitary conditions in the residents' rooms. The DON highlighted the potential risks of infection and falls due to the presence of feces and urine in the residents' rooms. The Administrator and DON acknowledged the need for more diligent reporting and addressing of cleanliness issues in resident rooms.
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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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Illustrative
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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) |
|---|---|---|---|---|
| West Oaks Nursing & Rehab Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Avir At Houston | 1.9 mi | ★★★★★ | 17 | 2 |
| Parkway Place | 2.8 mi | ★★★★★ | 1 | 0 |
| Continuing Care At Eagles Trace | 3 mi | ★★★★★ | 1 | 0 |
| St Dominic Village Rehabilitation And Nursing Cent | 3.6 mi | ★★★★★ | 2 | 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.