Above 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 West Oaks Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs. One resident, with severe cognitive impairment, was unable to reach his call light to request assistance, while another resident, awaiting hip surgery, found her call light inaccessible under her wheelchair. Staff were initially unaware of these issues, highlighting a lapse in ensuring residents could summon help when needed.
The facility failed to update care plans for two residents to include anticoagulants and oxygen therapy, despite physician orders and medical needs. One resident's care plan did not address anticoagulants and oxygen therapy, while another's lacked a focus on oxygen therapy despite a history of respiratory issues. Staff interviews revealed communication gaps in updating care plans, contrary to facility policy.
The facility failed to follow the prescribed menu for pureed meals, blending only 7 pieces of tilapia for 16 residents requiring pureed diets. The dietary staff member was unsure of the number of residents needing pureed meals and incorrectly believed she had blended enough fish. The interim dietary manager and dietitian confirmed the shortfall, and additional fish had to be prepared to meet the residents' needs. The facility's policy emphasized the importance of portion control to ensure residents receive adequate nutrition.
A resident with multiple medical conditions and a high risk for falls did not receive adequate supervision and assistive devices as required by his care plan and physician orders. The facility failed to provide two fall mats, as only one was observed in the resident's room, and staff interviews revealed the second mat was removed for cleaning and not replaced. The resident had an unwitnessed fall, and staff acknowledged the need for care plan updates to reflect the resident's current needs.
A facility failed to change a resident's midline IV dressing weekly as ordered by the physician, placing the resident at risk for infection. The resident, with a history of multiple health issues, had a midline IV for antibiotic administration. Despite the physician's order, the dressing was not changed on schedule, and staff interviews revealed a lack of awareness and oversight. The facility did not have a specific policy on IV/midlines, contributing to the deficiency.
A resident with a history of respiratory issues was found without her oxygen cannula, despite having a physician's order for continuous oxygen therapy. The DON acknowledged the oversight, noting that the care plan should have included the oxygen order. The resident's care plan lacked a focus area for oxygen, and the aide responsible forgot to replace the oxygen after removing it for a change. The facility's policy requires medications, including oxygen, to be administered as ordered.
A resident's medications, Furosemide and Gabapentin, were administered two hours late due to the medication aide being delayed on another hall. The facility's protocol allows for a one-hour window around scheduled times, and deviations are considered medication errors. The resident, with a history of heart disease and dementia, did not receive his medications at the scheduled 8:00 AM time, and the nurse was not notified of the delay.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating their needs. Resident #89, a male with severe cognitive impairment and multiple medical conditions, was observed lying in bed unable to reach his call light, which was on the floor. Despite expressing discomfort with the room temperature, he could not call for assistance due to the call light's inaccessibility. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) were informed of the issue, but initially, the call light remained out of reach, highlighting a lapse in ensuring the resident's ability to request help. Resident #310, a female awaiting hip replacement surgery, was also found with her call light cord underneath her wheelchair, making it inaccessible. She expressed feelings of being ignored by staff and was unaware of the call light's location. Despite interactions with staff, the call light remained on the floor until a Certified Nursing Assistant (CNA) was informed and rectified the situation. The resident's inability to reach the call light contributed to her distress and feelings of neglect, as she was unable to summon assistance when needed. Interviews with staff, including the Administrator and DON, revealed a lack of awareness regarding the call light issues for both residents. The facility's policy emphasized the importance of call lights being within reach to ensure residents can request assistance, yet this was not adhered to in these cases. The deficiency was identified through observations and interviews, underscoring the facility's failure to reasonably accommodate the residents' needs by ensuring call lights were accessible.
Failure to Update Care Plans for Anticoagulants and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. For one resident, the care plan did not address the use of anticoagulants and oxygen therapy, despite the resident's diagnoses of multiple sclerosis and acute respiratory failure with hypoxia. The resident's physician orders included anticoagulants and oxygen therapy, but these were not reflected in the care plan, indicating a lack of coordination between the resident's medical needs and the care plan. Another resident's care plan also lacked a focus area for oxygen therapy, despite the resident's medical history of pneumonitis, sepsis, and acute hypoxic respiratory failure. The resident had been admitted to the hospital for respiratory distress and was placed on oxygen therapy, which was later weaned to 2 liters. However, the care plan did not reflect the ongoing need for oxygen therapy, even though physician orders indicated continuous oxygen use. Observations showed the resident using oxygen, but the care plan was not updated to include this critical aspect of care. Interviews with facility staff, including the Director of Nursing (DON) and MDS Coordinator, revealed a lack of communication and oversight in updating care plans to reflect current physician orders and resident needs. The DON acknowledged that care plans should have been updated within 48 hours to include orders for anticoagulants and oxygen therapy. The facility's policy required care plans to be comprehensive and updated regularly, but this was not adhered to, resulting in inadequate care planning for the residents involved.
Failure to Follow Pureed Meal Menu and Portion Control
Penalty
Summary
The facility failed to adhere to the prescribed menu for pureed meals during the lunch service on January 15, 2025. An observation revealed that only 7 pieces of tilapia were blended for 16 residents requiring pureed diets, contrary to the required 16 pieces plus additional portions for double servings. The dietary staff member responsible for preparing the meal was unsure of the exact number of residents needing pureed diets and incorrectly believed she had blended 15 or 16 pieces of fish. Interviews with the interim dietary manager (IDM) and the dietitian confirmed that the facility had 16 residents requiring pureed meals, and the correct number of fish pieces should have been 23 to accommodate double portions. The IDM and dietitian observed that more than half a tray of fish remained after the initial blending, indicating insufficient preparation. The IDM had to retrieve additional fish from the freezer to ensure all residents received their meals, although the dietary manager later stated that there was enough fish available without needing to cook more. Further interviews revealed that the dietary staff member did not count the fish pieces during preparation and had to puree additional fish after being informed of the shortfall. The facility's policy and daily spreadsheet indicated the need for precise portion control to meet residents' nutritional needs. The dietary manager emphasized the importance of following recipes and portion control to ensure residents receive adequate nutrition, and staff were regularly in-serviced on these procedures.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide two fall mats for a resident as required by his comprehensive care plan and physician orders. The resident, who had a history of multiple medical conditions including chronic heart failure, vascular dementia, and cognitive impairment, was at high risk for falls. Despite this, his care plan did not include the necessary interventions for fall mats, and only one fall mat was observed in his room during multiple observations. The resident's physician orders, dated to start in early 2025, specified the need for two fall mats at the bedside for every shift. However, during observations, only one fall mat was present, and staff interviews revealed that the second mat was removed for cleaning and not replaced. The resident had experienced an unwitnessed fall earlier in the month, which was documented in his fall assessment and nursing progress notes. Despite being alert, the resident was unable to verbalize how he ended up on the floor, indicating a lack of adequate supervision and preventive measures. Interviews with facility staff, including a CNA, RN, and the DON, highlighted a lack of communication and updates to the resident's care plan. The RN mentioned that the care plan needed updating due to the resident's reduced mobility, while the DON and Administrator emphasized the importance of care plans in matching resident needs. The facility's policy on care plans, revised in January 2023, requires comprehensive and updated care plans to meet residents' needs, but this was not adhered to in the case of the resident in question.
Failure to Change Midline IV Dressing as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice and physician orders regarding the administration of intravenous (IV) fluids for a resident. Specifically, the facility did not change the midline IV dressing of a resident as ordered by the physician. The resident, a male with a history of pulmonary embolism, hemiplegia, hemiparesis, Type 2 diabetes mellitus, pneumonia, and heart failure, was admitted to the facility and had a physician's order for a weekly midline dressing change. However, an observation revealed that the dressing had not been changed since 01/06/25, despite the order for weekly changes. Interviews with facility staff, including an LVN, the Infection Control Nurse/ADON, and the DON, confirmed the oversight. The LVN, who was responsible for the resident's care, was unaware of why the dressing had not been changed. The Infection Control Nurse/ADON admitted to forgetting to check the dressing, and the DON acknowledged that the responsibility for ensuring the dressing change fell to the Infection Control Nurse. The facility lacked a specific policy on IV/midlines, which contributed to the oversight. The failure to change the dressing as ordered placed the resident at risk for infections and a decrease in quality of life.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy to a resident as per the physician's orders. On a specific date, the resident was observed without her oxygen cannula, despite having an order for continuous oxygen at 2-3 liters per minute. The Director of Nursing (DON) acknowledged the oversight and mentioned that the care plan should have included the oxygen order. The resident's care plan did not have a focus area for oxygen, and the DON admitted that the facility was in the process of auditing care plans. The resident had a history of respiratory issues, including pneumonia and acute hypoxic respiratory failure, which necessitated the oxygen therapy. The resident was initially admitted to the hospital for respiratory distress and was placed on oxygen, which was later reduced to 2 liters. Despite the stable oxygen saturation levels, the resident was found without the oxygen mask or tank while sitting in the hallway. The DON later confirmed that the aide responsible for the resident had removed the oxygen to change the resident and forgot to replace it. The facility's medication administration policy requires medications, including oxygen, to be administered as ordered by the physician, highlighting a lapse in adherence to this policy.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications to a resident at the scheduled time, specifically Furosemide and Gabapentin, which were supposed to be given at 8:00 AM. Instead, these medications were administered at 10:00 AM, two hours later than scheduled. This delay was observed during a medication pass and was attributed to the medication aide being occupied on another hall, causing her to fall behind schedule. The facility's protocol allows for medications to be administered one hour before or after the scheduled time, and any deviation from this is considered a medication error. The resident involved was an elderly male with a history of heart disease, dementia, peripheral artery disease, hypertension, and chronic pain. His care plan included the administration of a diuretic for leg edema and Gabapentin for neuropathy. The medication aide did not notify the nurse of the late administration, which is against the facility's protocol that requires notifying the nurse and potentially the physician in such cases. The Director of Nursing confirmed that not adhering to the scheduled medication times could affect the effectiveness of the medication.
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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) |
|---|---|---|---|---|
| Park Manor Of Westchase | 0.2 mi | ★★★★★ | 1 | 1 |
| Avir At Houston | 2.2 mi | ★★★★★ | 17 | 2 |
| Parkway Place | 3 mi | ★★★★★ | 1 | 0 |
| Continuing Care At Eagles Trace | 3.2 mi | ★★★★★ | 1 | 0 |
| St Dominic Village Rehabilitation And Nursing Cent | 3.7 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.