Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seven Acres Jewish Senior Care Services during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and recurrent falls had a fall mat listed in the care plan, but staff observed the mat missing when the resident was found on the floor with a skin tear and hand injury. Another resident with Alzheimer’s disease, dysphagia, and major unplanned wt loss had a care plan that still focused on being overweight and did not address the documented wt loss, low intake, supplements, or appetite stimulant use. A third resident with Down syndrome and dementia had no PASRR recommendations, NFSS, or therapy services included in the care plan, and the MDS nurse confirmed those items were omitted.
The facility failed to maintain infection control for residents with Candida auris and for a resident on EBP. Two residents with C. auris had inconsistent orders and signage, with staff showing confusion about whether contact precautions or EBP applied, and a family member was observed in one room without PPE. In another case, an LPN administered g-tube medications while wearing gloves but no gown, despite EBP signage requiring gown and gloves for feeding tube care.
Failure to Submit PASRR NFSS Request Within Required Timeframe: The facility failed to submit a complete and accurate NFSS request in the LTC portal within the required 20 business days after the PASRR IDT meeting for a resident with Down Syndrome, Alzheimer's disease, dementia, severe cognitive impairment, and mobility needs. The State PASSR Specialist and email correspondence confirmed the request was not submitted on time, and the DON stated another IDT meeting was held because the original deadline had passed.
A resident with conversion disorder with seizure, depression, and HTN was given medications in the day area in the presence of another resident, and the MA stated the resident's high blood pressure and seizure medications aloud during the pass. Interviews showed staff expected meds to be given in residents' rooms to protect dignity and privacy, and the MA acknowledged she knew privacy was required but did not provide it.
Call Light and Water Not Kept Within Reach of a Resident in Bed. A resident with dementia, severe cognitive impairment, and limited transfer ability was observed in bed with his call light unplugged and the button missing, and his water pitcher was placed out of reach on a tray table across the room. Staff interviews indicated the resident often asked for drinks from his refrigerator and that his water should have been at his bedside.
A resident with severe cognitive impairment, osteoporosis, weakness, unsteady gait, and a documented fall risk was found sitting on the floor beside her bed without the fall mat that was listed in her care plan. Staff observed blood on her hand and later documented a right-hand opening and skin tear after the unwitnessed fall. The Unit Manager, DON, and MDS Coordinator all stated the fall mat should have been at the bedside as part of her fall interventions.
Enteral Feeding Not Delivered as Ordered: A resident with a G-tube, dementia, dysphagia, and protein deficiency was ordered Jevity 1.5 Cal at 50 mL/hr with scheduled water flushes, but observations showed inconsistent labeling of the formula bag, reuse of the same bag across days, and mismatches between the pump reading and the physical amount of formula remaining. An LVN and the DON could not explain the discrepancies, and the resident did not receive the ordered amount of tube feeding formula.
A resident with seizure disorder, depression, and HTN had multiple meds documented by a CMA before they were actually administered. The RN, UM, DON, and ADM all stated meds should be documented only after administration, and the UM and DON identified the practice as a med error and falsification of records.
Multiple dependent, incontinent residents did not receive timely incontinence care and hygiene in accordance with their care plans and facility policy. Family members, supported by room camera footage, reported that some residents were left unchanged for approximately 14 hours overnight, despite care plans requiring incontinence checks at least every two hours. One cognitively intact resident reported that overnight staff frequently failed to check or change her several times per month. Staffing records showed a CNA assigned to the unit without clearly documented room assignments, and the CNA stated she was new and unaware of the full assignment list at the nurses’ station. The DON acknowledged that two residents were not changed during the overnight shift in question, while the facility’s incontinent care policy required monitoring rounds every two to three hours per shift.
A resident with hemiplegia, hemiparesis, and moderate cognitive impairment, care planned as dependent for transfers with a full body lift and two-person assist, was transferred by a CNA using a standing lift without a second staff member. The CNA reported being unable to find the full body sling and proceeded alone with the standing lift, despite facility expectations that two staff assist with all mechanical lifts. During the bed-to-chair transfer, the resident was lowered to the floor, later reported shoulder and knee pain, and was evaluated at a hospital, where no acute injuries were found.
Two residents experienced lapses in safety and supervision: one was injured when a CNA used a standing lift instead of the required Hoyer lift for transfer, resulting in lumbar fractures, while another resident with severe cognitive impairment was found unsupervised in the facility's parking lot after leaving the building in a wheelchair. In both cases, staff did not follow established care plans or supervision protocols, leading to actual harm and increased risk.
Incomplete care planning for falls, weight loss, and PASRR needs
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #14, who had diagnoses including bipolar disorder, osteoporosis, muscle wasting and atrophy, muscle weakness, gait and mobility abnormalities, lack of coordination, and dementia. Her quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment. Her care plan identified a fall risk and included an intervention to keep a high-density mat on the right side of the bed. However, observation on 6/23/2026 showed no fall mat at the bedside, and on 6/24/2026 the resident was found sitting on the floor on the right side of her bed without the fall mat in place. Staff documented that she had been found on the floor, had a skin tear and opening to the right hand, and x-rays were ordered for the right hand, hips, and knee. Later observations again showed the fall mat was not in the room, and staff interviews confirmed the mat should have been at the bedside as part of the fall interventions. The facility also failed to include Resident #21’s significant unplanned weight loss in the comprehensive care plan. Her diagnoses included Alzheimer’s disease, dysphagia, cerebral infarction, hemiplegia, dysarthria, vascular dementia, and hypertension. Her quarterly MDS coded weight loss not associated with a physician-prescribed weight loss regimen. The care plan, however, continued to identify her as overweight with a goal to maintain weight without significant weight gain and did not identify weight loss as a problem. The RD consult summary documented weight loss of 7.1% over 30 days and 14.0% over 90 days, with low intake and supplements and an appetite stimulant started. The NP stated treatment for unplanned weight loss had begun at the end of May and included protein supplements, appetite stimulant, and weekly weight monitoring, while the MDS nurse stated the care plan only addressed self-feeding difficulties. For Resident #80, the facility failed to include PASRR recommendations and NFSS in the comprehensive care plan. His diagnoses included Down syndrome, osteoarthritis, Alzheimer’s disease, cognitive communication deficit, dementia, and muscle wasting and atrophy. His admission MDS showed severe cognitive impairment and use of a walker for mobility. The care plan revision contained no documentation that the resident was PASRR positive, no PASRR needs, goals, interventions, or nursing facility specialized services, and it also did not indicate the PT and OT services he was receiving. The MDS nurse confirmed that these PASRR-related needs and specialized services were not included in the care plan.
Infection Control Deficiencies With Candida Auris Precautions and PPE Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 of 22 residents reviewed for infection control. The report states the facility did not follow its own infection control policy for Candida auris and did not ensure staff used complete PPE during g-tube medication administration for a resident on enhanced barrier precautions (EBP). For one resident, record review showed diagnoses including dementia and candidiasis, with severe cognitive impairment. Physician follow-up documents stated the resident was positive for Candida and that contact precautions were in place, but the resident did not have a physician order for isolation, quarantine, or EBP in the electronic record. Observations showed an EBP sign on the door, and staff interviews showed confusion about whether the resident had an infection and whether contact precautions or EBP applied. One LVN stated she was not aware the resident had C. auris. For a second resident, hospital records showed Candida auris confirmed and instructions to maintain isolation precautions. The resident’s care plan referenced isolation related to active infectious disease, but the orders did not indicate isolation precautions for Candida auris. During observation, an EBP sign was on the door and a family member was present without PPE. Staff interviews showed inconsistent understanding of the resident’s status, with some staff describing EBP, others describing contact isolation, and the DON stating the resident had a sign for EBP and would remain in a solo room. The facility policy reviewed stated residents with C. auris in nursing homes should be managed using contact precautions and should not be in general population during meals or therapy. For the third resident, who had diagnoses including infection of the bladder or kidney, pneumonia, acute respiratory failure, and a feeding tube, staff observed an LVN administering g-tube medications while wearing gloves but not a gown. The resident’s door posted EBP instructions requiring gloves and gowns for device care and feeding tube use. In interviews, the LVN, RN, wound care nurse, DON, and ADM all stated that a gown and gloves were expected for g-tube medication administration under EBP, and that not wearing the gown violated infection control policy.
Failure to Submit PASRR NFSS Request Within Required Timeframe
Penalty
Summary
The facility failed to coordinate PASRR assessments with the pre-admission screening and resident review program to the maximum extent practicable for Resident #80. Resident #80 was a male resident with Down Syndrome, osteoarthritis, Alzheimer's disease, cognitive communication deficit, dementia, and muscle wasting and atrophy. His admission MDS showed a BIMS score of 2, indicating severe cognitive impairment, and he used a walker for mobility. His care plan did not include a focus area for PASRR positive status. Record review showed the resident's PASRR Comprehensive Service Plan Form identified an updated PASRR Interdisciplinary Team meeting on 5/7/2026 and listed nursing facility specialized services including a customized manual wheelchair and specialized OT, PT, and speech therapy assessments and services. The facility's LTC Online Portal history showed the NFSS request was submitted on 5/21/2026. The State PASSR Specialist stated the facility had 20 days from the PASRR Interdisciplinary Team meeting to submit the request, but the facility had not submitted it within that timeframe. Email correspondence from the State Agency PASSR services to the Administrator and DON stated the facility was not in compliance with submitting the NFSS request within 20 days of the PASRR Interdisciplinary Team meeting. The DON stated she did the PASRR, that Resident #80 was the only PASRR resident, that the first PASRR IDT meeting was held on 3/26/2026, and that another PASRR IDT meeting was held because the 20 business day due date had passed.
Failure to Provide Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure personal privacy for one resident during medication administration when MA A gave the resident medications in the day area in the presence of another resident. During the observation, MA A stated she had the resident's high blood pressure and seizure medication and administered the medications outside the resident's room. The resident had diagnoses including conversion disorder with seizure, depression, and high blood pressure, and his MDS showed a BIMS score of 13 with mood coded as feeling down, depressed, or hopeless. Record review showed the resident's baseline care plan addressed recent family loss and included an intervention to provide opportunities to express feelings. Interviews with RN A, RN B, the UM, and the DON indicated that medications were to be administered in residents' rooms and that discussing medication names and uses in the presence of others was a privacy violation. MA A stated she was supposed to provide privacy and acknowledged she knew it was a violation to administer medications in the day area. The ADM stated she had seen medications given in common areas and did not consider that a privacy issue, while the resident stated he could not say anything even when he did not like what happened around him because staff were there to care for him.
Call Light and Water Not Accessible to Resident in Bed
Penalty
Summary
The facility failed to ensure Resident #12 had reasonable access to his call light and water while he was in bed. Resident #12 was admitted with osteoporosis, dementia, a displaced intertrochanteric fracture of the left femur, and abnormalities of gait and mobility. His care plan noted limited ability to transfer self and a need for maximum assistance of one person for transfers. His quarterly MDS assessment showed a BIMS score of 4, indicating severe cognitive impairment, and he required setup assistance with eating and could independently roll from his left to right in bed. During an observation and interview on 6/23/26, Resident #12 was lying in bed with his call light unplugged from the wall and the call light button not found. He stated he was thirsty and wanted something to drink from the refrigerator in his room, but his tray table was across the room against a wall and the water pitcher on it was inaccessible. A similar observation on 6/24/26 found him again in bed with the tray table against a wall and the water pitcher inaccessible. Staff interviews indicated the call light may have been unplugged during care, that the resident frequently asked for drinks from his refrigerator, and that his water should have been at his bedside. The facility policy stated call lights should be within reach and accessible while residents are in bed.
Fall Mat Not in Place for Resident With High Fall Risk
Penalty
Summary
The facility failed to ensure Resident #14’s environment remained as free of accident hazards as possible when her fall mat was not in place on the right side of her bed. Resident #14 was an [AGE]-year-old female with diagnoses including bipolar disorder, age-related osteoporosis, muscle wasting and atrophy, muscle weakness, abnormalities of gait and mobility, lack of coordination, and dementia. Her quarterly MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. Her care plan identified a fall risk related to muscle weakness and unsteady gait and included an intervention to keep a high-density mat on the right side of the bed. On observation, Resident #14 was seen lying in bed with her wheelchair at bedside and no fall mat on the floor. Later, she was found sitting on the floor on the right side of her bed with no fall mat in place. At that time, her right hand had blood on it, and NP S was in the room assessing her. Staff stated they were aware she was on the floor, and a nurse was coming to the room. The progress note documented that she was found sitting on the floor, had an opening to the right hand between the thumb and second finger, and was assisted back to her wheelchair. After the fall, Resident #14 had a bandage on her right thumb and a skin tear on her right forearm. She could not remember the fall or how she got on the floor. The Unit Manager, DON, and MDS Coordinator each stated that a fall mat should have been at her bedside as part of her fall interventions. The facility’s Fall Reduction Program policy stated that all residents would receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls, and that care plans would be created and implemented based on individual risk factors.
Enteral Feeding Not Delivered as Ordered
Penalty
Summary
The facility failed to ensure a resident receiving enteral feeding received the ordered amount of Jevity 1.5 Cal through a gastrostomy tube. The resident was an older female admitted with diagnoses including dementia, dysphagia, gastrostomy, protein deficiency, anemia, vitamin D deficiency, depression, osteomyelitis, lack of coordination, and polyneuropathy. Her record showed she was unable to repeat phrases or recall words and had difficulty or pain with swallowing. Her care plan included tube feeding with a goal of not exhibiting signs of complications from enteral feeding, and her physician order called for Jevity 1.5 Cal at 50 mL per hour for 21 hours, with water flushes of 100 mL every 4 hours. Observations on multiple days showed inconsistencies with the hanging formula container and the amount of formula delivered. On one day, the bottle label contained handwritten entries in different ink colors, with the resident’s name, room number, and start time written in black ink and the date and rate written in purple ink. The bottle level was observed at 700 mL from a 1,000 mL bottle after about 9 hours. The next day, the same bottle showed the resident’s name, room number, and start time still in black ink, while the day, year, and rate had been written over in black ink on top of purple ink. The bottle again measured 700 mL remaining after about 7 hours. On a later observation, the pump screen displayed 193 mL fed, while the bottle level showed only 50 mL had left the container, creating a discrepancy between the pump reading and the physical volume remaining. Staff interviews confirmed that formula bags were to be changed every 24 hours and labeled with the date, time, and initials of the nurse who hung the bag. An LVN stated the resident was to receive 50 mL per hour and that the pump reading reflected how much water was flushed or formula consumed, but she could not explain the discrepancy between the pump reading and the bottle contents. The DON reviewed the photos and stated the bag should not be used more than 24 hours, that mistakes on the label should be crossed out and initialed, and that the resident’s feeding should follow the MAR. The DON also stated the resident would be at risk of malnutrition if not receiving the correct amount of cc per day due to the same bag being used on both days.
Medication Administration Documented Before Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when staff did not ensure accurate documentation of medication administration for one resident. During an observation of medication administration, a CMA documented multiple medications for the resident before actually administering them, including hydralazine, levetiracetam, ranolazine, aspirin, clopidogrel, isosorbide mononitrate ER, nifedipine, omeprazole, and sertraline. The CMA stated she documented the medications prior to administration because the resident had never refused medications. Record review showed the resident was admitted with conversion disorder with seizure, depression, and high blood pressure, and his MDS coded a BIMS of 13 with mood indicating feeling down, depressed, or hopeless. In interviews, the RN, UM, DON, and ADM all stated medication documentation should occur only after administration, and the UM and DON identified documentation before administration as a medication error and falsification of medical records. The facility policy stated medications are administered as prescribed in accordance with good nursing principles and practices.
Failure to Provide Timely Incontinence Care and Hygiene for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically incontinence care and related hygiene, to multiple dependent residents during the overnight shift. Several residents were care planned to be checked for incontinence at least every two hours, yet family reports and video evidence indicated that incontinent care was not provided for extended periods. Resident #2, a female with dysphagia following a stroke, was documented as always urinary incontinent and dependent for toileting hygiene, with a care plan directing checks for incontinence at least every two hours. Her family member reported that on one occasion there were 14 hours during which she was not changed, from approximately 9 p.m. one night until the following day, and stated that this was part of an ongoing issue with overnight staff not checking and changing residents. Resident #3, a female with dementia but intact cognition per BIMS, was also documented as always urinary incontinent and dependent for toileting hygiene, with a care plan requiring checks for incontinence at least every two hours. Although observations during the survey found her clean, dressed, and without foul odors, she stated that her care was terrible and that there was not enough help. She reported that staff on the second and third shifts would shift responsibility to each other and that she had problems with the overnight shift not checking or changing her. She indicated that the overnight shift failed to check on her about three to four times a month, depending on which staff were working. Resident #4 and Resident #5, both females with dementia and always urinary incontinent, were also dependent for toileting hygiene and had care plans directing checks for incontinence at least every two hours. For Resident #4, a grievance from a family member alleged that she was not provided incontinent care on the 11 p.m. to 7 a.m. shift, and the family member reported that camera footage showed she was not changed for 14 hours and 37 minutes between a diaper change at 10:04 p.m. and the next change the following day. For Resident #5, a grievance and family interview indicated that she was put to bed in the evening and not checked or changed throughout the night, with camera footage and family notes indicating a gap of nearly 14 hours or more between diaper changes. Video review provided by a family member showed staff presence in the shared room at 10:04 p.m. and then not again until midday the next day, with no documented incontinence care during the overnight hours. The facility’s own incontinent care policy required monitoring by rounds every two to three hours per shift, which was not followed in these instances. Staff interviews further described the circumstances around these events. The daily staffing sheet for the 11 p.m. to 7 a.m. shift listed CNA B on the unit with these residents, but did not specify room assignments. CNA B stated she was new, received a written list of residents from another CNA, and was not aware of an assignment list at the nurses’ station that included additional residents. She reported that she provided care and vital signs to the residents she believed were assigned to her and denied neglecting any residents. Other CNAs working day shifts reported that residents were generally clean when they arrived and that night shift staff typically began changing residents around 5–6 a.m., and they denied current concerns about neglect. The DON acknowledged awareness that Resident #4 and Resident #5 were not changed on the night in question and described that CNA B had not looked at the assignment list at the nurses’ station. The facility’s incontinent care policy, last reviewed 6/6/25, specified that incontinent monitoring would be conducted by rounds every two to three hours per shift, which contrasted with the extended periods without incontinence care reported and documented for these residents.
Improper Mechanical Lift Use and Inadequate Assistance During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and to provide adequate supervision and use of appropriate transfer equipment during a mechanical lift transfer. A female resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and with moderate cognitive impairment (BIMS score of 8), was care planned as dependent for transfers and required use of a full body lift with two-person assistance. The resident’s care plan specified assistance with transferring using a full body lift with two staff, but the physician’s orders did not contain specific transfer or mechanical lift instructions. On the date of the incident, CNA A attempted to transfer the resident without following the care plan. CNA A reported that when a full body sling could not be found in the resident’s room, they used a standing lift instead. CNA A also stated that no one was helping with the standing lift because other staff were busy and that, although two people were usually used when not busy, on this occasion the transfer was performed alone. This was CNA A’s first time caring for the resident, and CNA A stated they did not know the resident was not supposed to use the standing lift and that they sometimes used a standing lift if full body lifts were busy. During the transfer from bed to chair using the standing lift, CNA A stated the resident chose to sit on the floor and was slowly lowered to the floor. The DON reported that the aide had to lower the resident to the floor during the transfer and then notified the charge nurse. The resident was assessed by nursing staff at the time and initially denied pain, with no injuries noted on head-to-toe assessment. Later, the resident complained of right shoulder and bilateral knee pain and was evaluated at the hospital, where imaging studies showed no acute intracranial abnormality and no fractures, and subsequent notes documented intact skin and no new orders. The unit manager stated that there were always supposed to be two people when transferring residents with either a standing or full body lift, and the facility’s transfer policy required use of the correct lift and two-person assistance for all lift transfers.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. In one case, a resident with severe cognitive impairment, limited mobility, and a history of lumbar compression fractures was transferred using a mechanical standing lift by a CNA, despite the resident's care plan specifying the use of a full body lift (Hoyer lift) and requiring a two-person assist. The CNA operated the standing lift alone, and during the transfer, the resident's foot slipped, causing her to fall to her knees and sustain additional compression fractures to her lumbar vertebrae. Multiple staff interviews confirmed that the standing lift was used at the request of the resident's family member, contrary to the care plan and physical therapy recommendations, and that some staff had previously used the standing lift for this resident due to family requests. In another incident, a resident with severe cognitive impairment and a history of dementia, acute kidney failure, and syncope was found unsupervised in the facility's parking lot in her wheelchair. The resident was not considered high risk for elopement according to her most recent assessment and had not previously exhibited exit-seeking behavior. Security camera footage showed the resident leaving the facility by following a family member out the door, remaining outside for several minutes before being returned to the facility by another family member. Staff interviews indicated that the resident was confused and forgetful, and that the doors were typically monitored by security, but it was unclear how the resident was able to exit the building without being noticed. Both incidents demonstrate failures in following established care plans and supervision protocols. In the first case, staff did not adhere to the prescribed transfer method and number of assisting personnel, and in the second, the facility did not ensure adequate monitoring to prevent a resident with cognitive impairment from leaving the premises unsupervised. These failures resulted in actual harm in the form of injury for one resident and placed both residents at risk for further harm.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Place Nursing Center | 1.4 mi | — | 0 | 0 |
| Houston Transitional Care | 1.7 mi | ★★★★★ | 2 | 0 |
| Paradigm At Westbury | 2.4 mi | ★★★★★ | 17 | 0 |
| Clarewood House Extended Care Center | 2.4 mi | ★★★★★ | 3 | 0 |
| Sharpview Residence And Rehabilitation Center | 2.6 mi | ★★★★★ | 1 | 0 |
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