Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Dominic Village Rehabilitation And Nursing Cent during CMS and state inspections, most recent first.
Failure to Submit Required Payroll Base Journal Staffing Data: The facility failed to electronically submit complete and accurate direct care staffing data to CMS for Q2 2026, including payroll and other verifiable auditable data for agency and contract staff. The CASPER report showed the required PBJ data was not submitted, and the Administrator said the omission was due to a transition in HR personnel. The HR Director stated she did not know why the PBJ was not submitted, and the facility policy assigned submission responsibility to the HR Director or designee.
Medication administration errors exceeded the allowed rate, with a 13% error rate found during observation and record review. A medication aide gave a resident chewable aspirin instead of EC aspirin and applied lidocaine patches to the wrong site, administered Vitamin D without an order to another resident, and gave cetirizine at a dose that did not match the ordered half-tablet. Interviews and MAR review confirmed the mismatches between physician orders and what was administered.
Missed Quarterly Fall Risk Assessment: A resident with metabolic encephalopathy, muscle weakness, gait abnormalities, and moderate cognitive impairment was care planned for fall risk related to immobility and incontinence, but his last fall risk assessment was not completed on a quarterly basis as required. The DON, ADON, and Infection Control Nurse/Education Coordinator stated fall assessments were to be done on admission, quarterly, and after falls, and the facility policy required reassessment at least quarterly and after any fall incident.
Missing immunization documentation for two residents. The facility did not document influenza or pneumococcal vaccine education, receipt, refusal, or contraindication in the records of a resident with moderate cognitive impairment and a resident with severe cognitive impairment. Both residents' MDS assessments showed incomplete vaccine information, their care plans did not address immunizations, and the EMR immunization tabs were blank. Staff stated vaccine history should be obtained on admission from the resident, family, or prior records, but the required documentation was not present.
Missing COVID-19 Immunization Documentation for Two Residents: The facility failed to document COVID-19 vaccine education, consent, receipt, refusal, or medical contraindication for two residents. One resident had moderate cognitive impairment and the other had severe cognitive impairment; both had no immunization information in the EMR, and staff interviews confirmed the admitting nurse was responsible for screening and documenting vaccine status, but the records were incomplete.
A cognitively intact resident with multiple medical conditions, including diabetic retinopathy, PTSD, and a lower leg amputation, gave an LVN his debit card and PIN so she could buy him food. The resident later learned from his bank that multiple unauthorized transactions totaling $800 had been made, and he reported that the LVN admitted to using some of his money and agreed to repay it. The LVN acknowledged having the card to purchase items but denied using it without the resident’s knowledge. The Activities Director and Administrator stated that only designated staff, such as the Activities Director, were allowed to purchase items or assist with resident funds, and both were unaware that this LVN was handling the resident’s card, contrary to facility policies prohibiting misappropriation and limiting financial assistance to designated staff.
The facility did not consistently update care plans to reflect new falls and interventions for several residents with significant medical and cognitive impairments. Although staff implemented measures such as low beds, clutter-free areas, and increased rounding after fall incidents, these actions were not documented in the care plans as required by facility policy. Communication about interventions occurred verbally among staff, but formal documentation was lacking.
Three residents experienced abuse when two residents with dementia were involved in a sexual incident without proper assessment of capacity to consent, and another resident with intact cognition reported being physically mistreated by a CNA during incontinence care. The facility lacked policies for determining consent to sexual activity, failed to update care plans after incidents, and did not document prior concerns about staff behavior.
Three residents with cognitive impairment did not have their care plans updated in a timely or accurate manner following significant behavioral incidents, including inappropriate sexual interaction and unprovoked behavioral symptoms. Staff interviews and record reviews confirmed delays and omissions in care plan documentation, despite facility policy requiring prompt interdisciplinary updates.
A medication cart was found unlocked and unattended in a hallway, with a resident's Timolol eye drops left on top and multiple drawers containing insulin pens, lancets, syringes, and other medications accessible. An LVN stated she left the cart unsecured while assisting another resident, and the DON confirmed that facility policy requires medication carts to be locked and supervised at all times.
Failure to Submit Required Payroll Base Journal Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS, including payroll and other verifiable and auditable data for agency and contract staff, for the second quarter of 2026. Record review of the CMS Payroll Base Journal Staffing Data Report (CASPER Report 1705D, Fiscal Year Quarter 2-2026) showed that the facility did not submit the required data for January 1 through March 31, 2026. During interview, the Administrator stated he had been at the facility since 2018 and said the Payroll Base Journal for the second quarter of 2026 was not submitted because of a transition in human resource personnel. He stated human resources was responsible for submitting the Payroll Base Journal. The Human Resource Director, who said she had worked at the facility for three weeks, stated she did not know why the Payroll Base Journal was not submitted and confirmed that human resources was responsible for ensuring it was completed. Record review of the facility policy titled Payroll Base Journal-Staffing, revised in August 2023, stated that the Human Resource Director or designee was responsible for submitting the Payroll Base Journal according to the CMS schedule.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors observed 4 medication errors out of 30 opportunities, resulting in a 13% error rate, involving 3 residents and 1 medication aide during medication administration observations and record review. The errors included giving the wrong form of aspirin to one resident, applying lidocaine patches to the wrong location for another resident, administering Vitamin D without a physician’s order to a third resident, and giving cetirizine at a dosage that did not match the ordered half-tablet dose. For one resident, the medication aide administered chewable aspirin 81 mg orally even though the order was for aspirin EC delayed release 81 mg. The same resident’s lidocaine patch orders were for application across the chest and between the shoulder blades, but the medication aide applied the patch to the resident’s right knee after asking where the resident wanted it placed. The MAR and progress notes reflected the patch orders and documented that the resident wanted the patch on the knee, with nursing staff later notified of the incorrect placement. For another resident, the medication aide administered Vitamin D 25 mcg even though no physician’s order for Vitamin D was found in the order summary report or MAR. For a third resident, the order was for cetirizine HCl 10 mg, 0.5 tablet by mouth daily, but the medication aide administered cetirizine hydrochloride 10 mg and stated the tablet did not have a score line, so it could not be split as ordered. Interviews with nursing staff and the medication aide confirmed the discrepancies between the ordered medications and what was administered.
Missed Quarterly Fall Risk Assessment
Penalty
Summary
The facility failed to ensure Resident #9 had quarterly fall risk assessments completed. Resident #9 was a male admitted with diagnoses including metabolic encephalopathy, muscle wasting and atrophy, lack of coordination, generalized muscle weakness, weakness, and unspecified abnormalities of gait and mobility. His annual MDS showed a BIMS score of 9, indicating moderate cognitive impairment, and his care plan identified him as being at risk for falls related to immobility and incontinence with intervention to follow the facility's fall protocol. Record review showed Resident #9's last quarterly Fall Risk Assessment was completed on 11/10/2025, and the assessment documented that he had not had any falls in the past three months. During interviews, the DON, ADON, and Infection Control Nurse/Education Coordinator stated that fall assessments were completed on admission, quarterly, and after each fall, and that missing an assessment could result in missed interventions for resident safety. The facility's policy stated that reassessment of fall risk shall be conducted at least quarterly and after any fall incident.
Missing Immunization Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records for two residents included documentation of influenza and pneumococcal immunization education, receipt of the vaccines, or a documented reason the vaccines were not given due to medical contraindication or refusal. The deficiency involved Resident #3 and Resident #65, whose records did not show evidence that they or their responsible parties received education about the benefits and potential side effects of the influenza immunization, or documentation of pneumococcal immunization status, refusal, or contraindication. Resident #3 was a male admitted with vascular dementia and had a BIMS score of 10, indicating moderate cognitive impairment. His quarterly and admission MDS assessments showed he did not receive the influenza vaccine in the facility and was not present during the influenza vaccination season, but the records did not include pneumococcal vaccination information. His care plan did not address immunizations, and the electronic medical record immunization tab did not contain immunization information. Resident #65 was a male admitted with cellulitis of the right lower limb and had a BIMS score of 3, indicating severe cognitive impairment. His admission MDS showed he did not receive the influenza vaccine in the facility and was not present during the influenza vaccination season, and also indicated his pneumonia and COVID-19 vaccinations were not up to date. His care plan did not address immunizations, and the immunization tab in the electronic medical record was blank. During interview, the ADON stated the facility did not have consent forms or immunization information for Resident #65, that he was combative and not agreeable at times, and that staff would try to contact family or obtain verbal information if needed. The DON stated immunization history should be completed on admission and that if vaccine data was not available, it should be documented in a nurse's note. The facility policies stated that on admission the resident or responsible party should be presented with informed consent for influenza vaccination and that the medical record should be reviewed to determine pneumococcal vaccination history.
Missing COVID-19 Immunization Education and Documentation
Penalty
Summary
The facility failed to implement its policy to ensure residents or their responsible parties received education on the benefits, risks, and potential side effects of COVID-19 immunization, and to document whether the vaccine was received, refused, or not given due to medical contraindication for 2 of 5 residents reviewed. The deficiency involved Resident #3 and Resident #65, and the report states that the lack of documentation could place residents at risk of not being informed of complications and potential adverse health outcomes. Resident #3 was a male admitted with vascular dementia, and his quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. His admission and quarterly MDSs did not include COVID-19 vaccination information, his care plan did not address immunizations, and his electronic medical record had no information in the immunization tab. Resident #65 was a male admitted with cellulitis of the right lower limb, and his admission MDS showed a BIMS score of 3, indicating severe cognitive impairment. His MDS indicated that pneumonia and COVID-19 vaccinations were not up to date, but his care plan did not address immunizations and his electronic medical record also lacked immunization documentation. During interview, the ADON stated the facility did not have consent forms for Resident #65 and that the medical record did not contain vaccine information. She said the resident was combative and not agreeable at times, and that the facility would call the family to obtain consent or ask whether he had received the vaccines. The DON stated immunization history should be completed as soon as records are received and that if vaccine data was not available, it should be documented in the nurse's note. The Unit Manager for Resident #3 stated the admitting nurse was responsible for screening for vaccinations and that if the resident refused immunizations, it should have been documented. The Infection Control Nurse and Education Coordinator stated the admitting nurse was responsible for screening residents for immunizations and offering the vaccine.
Misappropriation of Resident Funds by Non‑Designated Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from misappropriation of funds by a staff member. The resident, an adult male with diabetic retinopathy, lack of coordination, muscle weakness, PTSD, and a left lower leg amputation, had a BIMS score of 15 on a recent MDS, indicating he was cognitively intact. He reported that he trusted an LVN and gave her his debit card and PIN so she could buy him food. Later, his bank contacted him about a declined $300 payment and informed him that multiple small unauthorized withdrawals totaling $800 had been made from his account. The resident stated that only his son and the LVN had access to his card. After learning of the unauthorized transactions, he contacted his bank to stop the card and issue a new one. He reported that he confronted both his son and the LVN; according to the resident, the LVN admitted to using some of his money and agreed to repay it, which the resident stated she did through installments from her paychecks. The resident did not report the incident to the facility and stated this was the first and only time such an incident had occurred. A banker confirmed that the bank’s call center generated a report of declined transactions of $300, $100, $50, and $200 on the resident’s card, and that the resident said he had not authorized those transactions. The LVN acknowledged that the resident had given her his bank card to purchase items but denied using the card or the resident’s money without his knowledge. The Activities Director, who had long tenure at the facility, stated that she was the only staff member designated to purchase items for residents and that she was unaware of any other staff, including the LVN, doing so. The Administrator similarly stated that residents needing items could ask the Activities Director, that only designated staff should assist with resident funds, and that he had instructed staff not to take residents’ money or cards. He reported being unaware that this resident had a credit card in his possession and that he expected the LVN to direct the resident to the Activities Director and notify him so purchases could be tracked. Facility policies on abuse, neglect, and misappropriation, and on residents’ funds, specified that residents have the right to be free from misappropriation and that only designated staff may assist in managing resident funds.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents following fall incidents. For four out of five residents reviewed, the care plans were not updated to reflect new falls and the interventions that were put in place. Specifically, after each fall event, interventions such as low beds, clutter-free areas, increased rounding, lab orders, and nighttime snacks were implemented by staff, but these were not documented in the residents' care plans. This lack of documentation was observed despite the facility's policy requiring care plans to be updated after changes in a resident's condition or following incidents such as falls. Residents affected had significant medical histories, including conditions such as stroke, hemiplegia, Alzheimer's disease, muscle weakness, and impaired cognition. These residents were dependent on staff for activities of daily living and were at high risk for falls. In several cases, falls were witnessed or discovered by staff, and immediate interventions were initiated, such as neuro checks and physical assessments. However, the care plans did not reflect the most recent falls or the specific interventions that were implemented in response to those incidents. Interviews with facility staff, including the DON, MDS Coordinator, nurses, and CNAs, revealed that while interventions were communicated verbally during shift changes and through other informal means, the formal care plans were not consistently updated. The MDS Coordinator relied on notifications from the Fall Committee or Unit Managers to update care plans, and if not informed, updates were not made. Staff acknowledged that interventions were being carried out but admitted that documentation in the care plans was lacking. Facility policies reviewed also emphasized the need for interdisciplinary involvement and timely updates to care plans following changes in resident condition, which was not consistently followed.
Failure to Protect Residents from Sexual and Physical Abuse Due to Lack of Policy and Inadequate Care Planning
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse, as evidenced by two separate incidents involving three residents. In the first incident, a staff member observed a male resident with moderate cognitive impairment (BIMS scores of 10-11, diagnosed with dementia) with his mouth on the breast of a female resident with severe cognitive impairment (BIMS scores of 6-7, also diagnosed with dementia). The female resident was assessed as lacking the capacity to make informed decisions, and both residents' care plans did not address the incident or any sexual behaviors. Interviews with staff revealed that the care plans should have been updated to reflect the incident, but this was not done. The facility did not have a policy or procedure in place to assess or determine capacity to consent to sexual activity, and there was no documentation or assessment of consent for sexual activity in the residents' records or admission packets. In the second incident, a male resident with intact cognition and total dependence on staff for toileting care reported that a CNA pushed his face into the bed railings during incontinence care. The resident stated he had to yell at the CNA to stop and subsequently requested that she no longer provide care to him. The resident did not sustain injuries or report feeling unsafe, but described the CNA as typically rough and rude. Other residents had previously complained about the CNA's care, and staff interviews confirmed that her demeanor was often perceived as combative or assertive. The facility did not have documentation of prior interventions or conversations with the CNA regarding her care practices. The facility's policies at the time did not address the determination of capacity to consent to sexual activity, nor did they provide guidance on how to assess or document such capacity. Staff interviews indicated a lack of clarity and responsibility regarding updating care plans after behavioral incidents. The facility's abuse and neglect policy did not include procedures for assessing consent to sexual activity, and the admission packet did not address this issue. The absence of these policies and procedures contributed to the failure to protect residents from abuse and to ensure their care plans reflected significant incidents affecting their safety and well-being.
Failure to Timely Update and Accurately Reflect Resident Needs in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulation. For two residents with dementia and cognitive impairment, an incident involving inappropriate sexual interaction was not documented in their care plans in a timely manner. The incident occurred between a male and a female resident, both of whom had moderate to severe cognitive deficits and required significant assistance with activities of daily living. Despite the incident being reported and discussed among staff and with responsible parties, the care plans for both residents were not updated to reflect the event or to include specific interventions until more than a month later. Additionally, the facility did not ensure that the care plan for a third resident accurately reflected her behavioral symptoms. This resident, who had severe cognitive impairment and was bedbound, exhibited behaviors such as yelling without stimulus and fighting the air. However, these behaviors were not consistently documented in her medical record or reflected in her MDS assessment. Interviews with staff revealed a lack of communication and documentation regarding the resident's behaviors, leading to an incomplete and potentially inaccurate care plan. The facility's own policy requires an interdisciplinary approach to care planning, ongoing assessment, and timely updates to care plans when residents' conditions change or after significant events such as hospital readmissions. Despite this, the care plans for the affected residents were not promptly or accurately updated following behavioral incidents or changes in condition, as confirmed by staff interviews and record reviews.
Unattended and Unlocked Medication Cart with Accessible Medications
Penalty
Summary
Surveyors observed that the Unit 2-B nursing medication cart was left unlocked and unattended in a hallway, with a vial of Timolol eye drops for a resident placed on top of the cart. The drawers of the cart were found to be unlocked and contained various medications and medical supplies, including multiple insulin pens in use for several residents, lancets, pen needles, syringes, topical medications, and other items. The cart was positioned in front of a patient room, with its drawers easily accessible from the hallway. During interviews, the LVN responsible for the cart acknowledged that medications should be stored in locked carts and that the cart must be locked when not under direct supervision. She stated she left the medication on top of the cart and forgot to lock it because she was called away to assist another resident. The DON confirmed that facility policy requires medication carts to be locked and supervised at all times, and that failure to do so could result in unauthorized access to medications or injuries. Review of the facility's policy corroborated these expectations, stating that medication carts must never be left unlocked or unattended, and medications should not be left on top of the cart.
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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) |
|---|---|---|---|---|
| Garden Terrace Healthcare Center Of Houston | 1.1 mi | ★★★★★ | 8 | 1 |
| The Methodist Hospital Snf | 1.1 mi | ★★★★★ | 0 | 0 |
| Holly Hall | 1.7 mi | ★★★★★ | 15 | 0 |
| Bayou Manor | 3.9 mi | ★★★★★ | 4 | 0 |
| Harmony Care At Golfcrest | 4.1 mi | ★★★★★ | 7 | 0 |
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