Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 West Oaks Nursing & Rehabilitation during CMS and state inspections, most recent first.
Incontinent care was not properly completed for a resident with bowel and bladder incontinence, severe cognitive impairment, and dependence for ADLs. During observation, a CNA and the Staffing Coordinator found feces in the resident’s peri area and had to wipe the area multiple times before it was clean; the back of the brief also had faint streaks of stool. The CNA and Staffing Coordinator stated the resident had a lot of bowel movement in the peri area, and the DON said staff were expected to follow the facility’s incontinent care policy.
Unsafe Transfer Resulted in Leg Laceration: A resident with ESRD, morbid obesity, DM2, HF, PVD, and anxiety had an assessed need for 2-person transfer assistance, but staff performed a wheelchair-to-bed transfer with only one aide. During the transfer, her leg struck the bed grab handle and she sustained a deep laceration requiring stitches and hospital transfer. Interviews and records showed conflicting staff understanding of whether she needed 1 or 2 people for transfers.
Food Storage and Handling Deficiencies in Kitchen: Surveyors found multiple kitchen food safety issues, including deli ham and sliced cheeses in the refrigerator with no date or used-by date, milk on the serving table at 45 degrees F, a food rack stored only 2 1/2 inches off the floor, a scoop left in a flour bin, and a can opener blade with food debris. The Dietary Food Service Manager stated that leftover foods in the danger zone should have been discarded and that she was responsible for meeting the requirements.
Incomplete Foley and Incontinent Care: A resident with an indwelling Foley and incontinent care needs did not receive full perineal and catheter cleansing during CNA care. The CNA did not don a gown, did not wash hands, did not change gloves, and failed to clean the back scrotum, penile foreskin, penile head, and catheter before applying a clean brief. The CNA stated she forgot and acknowledged the missed steps could cause infection, skin break, and odors.
Failure to Verify G-Tube Placement Before Meds: A resident with a g-tube, severe cognitive impairment, functional quadriplegia, and total dependence on staff had medications administered through the tube without placement being checked first. The RN acknowledged forgetting to verify placement, and the DON stated placement should be checked before meds and water via the tube.
A CNA failed to follow EBP during incontinent and Foley catheter care for a resident with a urinary catheter, including not wearing a gown, not performing hand hygiene, and not changing gloves between tasks. In a separate event, an RN poured liquid iron into a medication cup and then returned it to the original bottle before giving a new dose to a resident with a GT, severe cognitive impairment, and multiple complex diagnoses. The DON stated staff had been trained on EBP and hand washing, and the facility policy for incontinent care called for care to be provided without cross contamination.
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.
Incontinent Care Failed to Remove Feces From Resident’s Perineal Area
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bowel and bladder received appropriate incontinent care to keep the perineal area free of feces. The resident was admitted with diagnoses including hypertension, hemiplegia, and cerebral infarction, had a BIMS score of 02 out of 15 indicating severely impaired cognition, and was dependent on staff for ADL care. Her care plan addressed incontinence related to self-care deficit and directed staff to check and change her during rounds and as needed. During an observation, CNA A provided incontinent care with the Staffing Coordinator assisting. When the brief was opened, the front was clean and dry, but repeated wiping of the resident’s peri area revealed substantial feces from the vaginal area on multiple wipes before the area became clean. The back of the brief had faint streaks of feces, and the resident was not having a bowel movement at the time. CNA A also cleaned the rectum and buttocks several times before the wipes were clean. The Staffing Coordinator and CNA A both stated the resident had a lot of bowel movement in her peri area and that if she was not cleaned properly it could lead to infection. The DON stated staff were expected to follow the facility’s incontinent care policy.
Unsafe Transfer Resulted in Leg Laceration
Penalty
Summary
The facility failed to ensure that Resident #24 was transferred according to her assessed assistance needs and failed to maintain a safe transfer environment. Resident #24 was a [AGE]-year-old female with end stage renal disease, morbid obesity, type 2 diabetes mellitus, heart failure, peripheral vascular disease, and anxiety disorder. Her admission screening identified a self-care deficit and specified 2-person assistance with transfers and toilet transfers. Her record also showed substantial to maximal assistance for bed mobility and chair or bed-to-chair transfers, and her care plan initially reflected 2-person transfer assistance. On 03/03/2026, Resident #24 sustained a laceration to her right lower leg during a transfer from her wheelchair to her bed. Nursing documentation stated that while staff were assisting her back to bed, her right leg hit the grab handle of the bed and caused active bleeding. She was wrapped with an ace wrap, the wound care physician was notified, and she was sent to the hospital. Hospital records documented that the laceration required repair with stitches, and the wound later measured 10.94 cm by 1.66 cm. Resident #24 reported that she told CNA B she needed another CNA to help, but CNA B proceeded with the transfer without a second person. The record contained conflicting accounts about whether Resident #24 was a 1-person or 2-person assist at the time of the incident. Therapy and nursing staff gave differing descriptions of her transfer ability, and the care plan was revised around the time of the event to reflect 1-2-person assistance and later a mechanical lift with 2 team members. Interviews showed that staff did not have a consistent understanding of her transfer needs, and the DON, LVN A, CNA B, and therapy staff gave different statements about how much assistance she required and what was communicated before the injury. The report also noted that the facility did not have a policy on maintaining resident beds.
Food Storage and Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. During a kitchen observation on 03/10/26 at 8:00 a.m., surveyors found a can opener blade with food debris, an open package of deli ham in the refrigerator with no used-by date, a package of sliced Swiss cheese with no date or used-by date, and a package of sliced cheddar cheese with no used-by date. A tray of milk in glass on the serving lunch table was measured at 45 degrees Fahrenheit, and a food rack in the storeroom was only 2 1/2 inches off the floor. A scoop dispenser was also left in a flour bin. During interview, the Dietary Food Service Manager stated that deli ham, Swiss cheese, and sliced cheddar cheese stored in the refrigerator for later use should have been discarded prior to the use-by date, and that leftover food in the danger zone between 40 degrees Fahrenheit and 140 degrees Fahrenheit should have been discarded. The manager stated she was responsible for meeting the requirements and would in-service dietary staff on proper handling, storing, and dating leftover food for compliance. Record review of the facility's Food Safety policy stated that potentially hazardous leftover foods are to be properly covered, labeled, dated, and refrigerated immediately, discarded on the used-by date unless otherwise indicated, and that food racks should be kept at least 6 inches off the floor.
Incomplete Foley and Incontinent Care
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not ensured for one resident with an indwelling Foley catheter and incontinent bladder care needs. The resident was an older male with diagnoses including muscle wasting and atrophy, dysphagia, cognitive communication deficit, unsteadiness on feet, generalized muscle weakness, obstructive and reflux uropathy, hypertension, and urinary tract infection. His quarterly MDS showed a BIMS score of 13 out of 15, indicating intact cognition, and he required staff assistance with ADLs. His care plan identified him as totally dependent for personal hygiene and toilet use and included Foley catheter care and incontinent care with ordered daily and as-needed cleansing and perineal hygiene. During observation of Foley catheter and incontinent care, CNA A did not don a gown, did not wash hands, and wore clean gloves while handling the resident’s brief and wipes. The CNA cleaned the groin and front scrotum and then the buttocks area, but did not clean the back side of the scrotum, penis foreskin, penis head, or indwelling catheter before fastening the clean brief. The CNA also did not change gloves before placing the clean brief under the resident. In interview, the CNA stated she forgot to clean the back side of the scrotum, penis foreskin, penis head, and indwelling catheter, and acknowledged that not doing so could cause infection, skin break, and odors. She also stated she forgot to wear PPE during incontinent care and knew that not wearing PPE could cause infection to herself and residents.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications of enteral feedings, including checking g-tube placement before administering medication. Resident #108 was admitted and re-admitted with diagnoses including gastrostomy, GERD without esophagitis, aphasia following cerebrovascular disease, functional quadriplegia, severe protein-calorie malnutrition, and tracheostomy status. The resident’s MDS reflected a BIMS score of 0 out of 15, indicating severe cognitive impairment, and that the resident was totally dependent on staff for bed repositioning and personal hygiene, and incontinent of bladder and bowel. During medication administration observation, RN H removed the resident’s g-tube feeding, administered medications through the tube, and did so without checking for placement first. The resident had physician orders to check gastric tube placement by auscultation prior to meds, formula, and water flushes every shift, and the facility policy titled Medication Administration Via Enteral Tube Care required auscultation for placement before administering medications through an enteral tube. When interviewed, RN H stated he forgot to check placement and acknowledged that not checking could cause aspiration pneumonia, bloating, being too full, and death. The DON stated nurses should check g-tube placement by visual inspection and for aspirated stomach content prior to administering medication and water.
Infection Control Failures During Resident Care and Medication Handling
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program for two residents reviewed for infection control. One resident had a Foley catheter and was on Enhanced Barrier Precautions, with orders for daily and as-needed Foley catheter cleansing and perineal hygiene. During observed incontinent and Foley catheter care, a CNA donned PPE but did not wash hands, handled clean supplies, and did not change gloves when moving from one task to another. The CNA later stated she forgot to change gloves and wear a gown during the care. A second event involved medication administration for a resident with a gastrostomy tube, severe protein-calorie malnutrition, aphasia, functional quadriplegia, tracheostomy status, and severe cognitive impairment. During observation, an RN removed liquid iron supplement from the medication cart, poured 6 cc into a medication cup, then poured the liquid back into the original bottle after stating he needed to check the resident’s blood pressure. After checking the blood pressure, the RN returned to the cart and poured out another 5 cc of iron supplement. When interviewed, the RN stated it was hygienic because the medication was clean. The DON stated that residents with urinary catheters were placed on Enhanced Barrier Precautions and that staff had received training on the use of EBP and hand washing. The DON also stated that if iron supplement was poured from the medication cup back into the bottle, she would have wasted it, but she was not sure what the policy said and needed to look into it. The facility policy for incontinent care stated that care should be provided in a manner that ensures no cross contamination.
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 | ★★★★★ | 15 | 1 |
| Avir At Houston | 2.2 mi | ★★★★★ | 27 | 2 |
| Parkway Place | 3 mi | ★★★★★ | 1 | 0 |
| Continuing Care At Eagles Trace | 3.2 mi | ★★★★★ | 0 | 0 |
| West Houston Rehabilitation And Healthcare Center | 3.8 mi | ★★★★★ | 6 | 0 |
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