Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgecrest Rehabilitation Suites during CMS and state inspections, most recent first.
Surveyors found that an exit door at the end of one resident hallway was left unlocked and repeatedly opening and closing, allowing unrestricted resident access without an alarm sounding. A CNA had used a key code to bring a resident in from outside and then exited again without confirming the door re-secured or that the alarm reactivated, later stating she believed it locked automatically and did not check it. A resident sitting nearby reported the door had been opening and closing and said it was not usually left unlocked and should always be locked. An LVN, the DON, and the Administrator all stated that exit doors were expected to remain locked and that staff who unlocked them were responsible for ensuring they were secured, and staff also reported there was no written policy addressing keeping exit doors locked or secured.
A resident with paraplegia, moderately impaired cognition, total dependence for transfers and lower body ADLs, and use of a mechanical lift was discharged to a personal care home without a complete discharge summary or adequate communication of needs. Key sections of the discharge documentation, including mobility, self-care, continence, medical equipment, services, and discharge destination, were left blank, and the continuity of care documents were not sent until several days after discharge. The receiving personal care home was not informed that the resident required maximum assistance and a hospital bed, and the resident arrived to a room with only a low twin bed and insufficient staff to manage her immobility, while no timely DME orders or home health coordination were documented prior to discharge.
A deficiency was identified when a CNA paused and restarted a tube feeding pump and adjusted the head of bed for a resident with a gastrostomy tube without nurse involvement, contrary to facility policy. The resident, who had severe cognitive and physical impairments and required total assistance, was not properly managed according to established procedures, as confirmed by staff interviews and policy review.
Surveyors observed that both dumpster lids were left open and garbage, including gloves, a mask, a bag of trash, a tin can, and papers, was found on the ground next to the dumpsters. Staff interviews confirmed that all staff are responsible for closing dumpster lids and ensuring trash is placed inside, but these procedures were not followed. No policy on garbage and refuse disposal was provided during the survey.
A medication aide in an LTC facility mistakenly prepared Hydrochlorothiazide for a resident instead of the prescribed Hydralazine due to a mix-up in the medication cart. The error was caught by a surveyor before administration. The resident, with a history of hypertension and moderate cognitive impairment, was at risk due to this error. The DON confirmed the importance of following the rights of medication administration.
The facility failed to provide a safe, clean, and homelike environment for two residents, as their rooms had peeling paint, dirty feeding tube apparatuses, and poorly maintained furniture. Both residents, who were dependent on feeding tubes and had cognitive impairments, were found in these conditions over several days. Interviews revealed a lack of clear cleaning policies and ineffective implementation of the facility's checklist meant to address such issues.
The facility failed to update care plans for several residents, leading to discrepancies between documented medical needs and care plans. A resident's recent fall was not included in her care plan, another's hospice care and UTI treatment were omitted, a third resident's diet was not updated after a choking incident, and a fourth resident's PEG tube feeding rate was not revised. These omissions could risk unmet medical, physical, and psychosocial needs.
The facility failed to refer two residents with serious mental disorders for Level II PASARR evaluations upon significant changes in their status. One resident with major depressive disorder, intermittent explosive disorder, and psychotic disorder was not referred for a Level II review, and another resident with Alzheimer's, schizoaffective disorder, and major depression was similarly overlooked. Interviews revealed a lack of proper PASRR follow-up and absence of a specific facility policy, contributing to the oversight.
A facility failed to maintain an effective infection prevention and control program when an LVN did not adhere to Enhanced Barrier Precautions while administering medications to a resident with a PEG tube. Despite the presence of a precaution sign, the LVN only wore gloves, neglecting to wear a gown as required. The resident had multiple complex medical conditions and was dependent on a PEG tube for nutrition. The facility's policy mandates the use of gowns and gloves during high-contact care activities to prevent cross-contamination and infection spread.
Unsecured Exit Door on Resident Hallway Allowing Unrestricted Access
Penalty
Summary
Surveyors identified a deficiency in maintaining a secured exit door on the 100 hall, resulting in unrestricted resident access to an unlocked and unalarmed exit. During observation, a CNA used a key code to open the back exit door to escort an unidentified resident from outside into the facility, then exited again through the same door without verifying that it re-secured or that the alarm system reactivated. After the CNA’s use, the door was observed repeatedly opening and closing due to the wind, and the surveyor was able to enter and exit multiple times, including holding the door open during an interview, without any alarm sounding. A resident seated near the door reported that the exit door had been opening and closing while she was looking outside and stated that the door was not typically left unlocked, describing it as dangerous and saying it should always be locked. In interviews, an LVN, the CNA, the DON, and the Administrator all stated that exit doors were expected to remain locked and that staff who unlocked a door were responsible for ensuring it was re-secured, with several identifying that a resident could leave the building if the door remained unsecured. The CNA reported she believed the door locked automatically and did not check it, and facility staff reported there was no written policy regarding exit doors remaining locked or otherwise always secured.
Incomplete Discharge Planning and Communication for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and properly planned discharge for a cognitively impaired, paraplegic female resident with multiple comorbidities, including pressure ulcers, bladder infection, GERD, diabetes with neuropathy, hypertension, generalized muscle weakness, and abnormal gait and mobility. The resident’s MDS and care plan documented moderately impaired cognition, total dependence on staff for lower body dressing, toileting, transfers (including sit-to-stand, bed-to-chair), and wheelchair mobility, as well as complete incontinence of bowel and bladder. She required a mechanical lift for transfers and maximum assistance for bed mobility and lower body ADLs, and therapy records recommended home health services at discharge. Despite these documented needs, the facility discharged the resident to a personal care home without completing an accurate and comprehensive discharge summary or plan. Progress notes indicated that the social worker had discussed discharge options, including another facility and a personal care home, and that home health had offered to assist upon discharge. However, there was no documentation that the facility obtained or documented the address of the discharge location in the discharge summary, and key sections of the discharge documentation were left blank, including physical functioning and structural problems (mobility devices, self-care, mobility), care team, scheduled appointments, special instructions (dietary/nutrition and therapy), medical equipment, continence, and customary routine. The transition of care/discharge summary did not specify the necessary equipment, such as a mechanical lift or hospital bed, or the services the resident would require after discharge. The facility also failed to timely communicate the resident’s clinical information and functional limitations to the receiving personal care home and to arrange necessary DME and services prior to discharge. There was no documentation that clinical records were sent to the personal care home before the resident’s transfer, and the discharge packet, including the continuity of care document and discharge summary, was not faxed until six days after the resident left. Interviews with the personal care home owner and transportation staff revealed that the resident arrived to a room with only a low twin bed, no hospital bed, and that the personal care home had not been informed that the resident required maximum assistance and could not transfer herself. The administrator and family member confirmed that the personal care home was not notified of the required DME prior to the resident’s arrival and that there was no documentation of DME orders or home health coordination before discharge, despite facility policy stating that all aspects of transfer and discharge must be documented and that sufficient preparation and orientation must be provided for a safe and orderly transfer or discharge. The facility’s internal investigation and administrator interview further established that the social worker responsible for the discharge did not order DME or fax a home health referral prior to discharge, and that there was no documentation of clinical information being sent to the personal care home at the time of transfer. The administrator acknowledged that discharge planning should begin at admission and that all services should be initiated prior to discharge, but in this case, the discharge summary was incomplete and lacked essential information such as the discharge destination, needed services, and equipment. The facility’s policy on admission, discharge, and transfer required documentation of all aspects of transfer and discharge, including patient/family notification and physician orders, and required sufficient preparation for a safe and orderly transfer, but the report notes that the policy did not provide further details on coordinating safe and orderly transfers, and the documented practices for this resident did not meet those stated requirements.
Failure to Follow Protocol for Tube Feeding Pump Operation
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) paused a resident's tube feeding pump and lowered the head of the bed (HOB) without notifying a nurse, contrary to facility policy. The resident involved had multiple complex medical conditions, including multiple sclerosis, muscle wasting, dysphagia, Parkinsonism, functional quadriplegia, and required a gastrostomy tube for nutrition. The resident was cognitively impaired, required total assistance for activities of daily living, and was dependent on staff for all care. During observation, the resident was found leaning to one side with the HOB appropriately elevated and the tube feeding pump running. The CNA repositioned the resident, paused the feeding pump, lowered the HOB, and then raised it again before restarting the pump, all without nurse involvement. The CNA stated she believed aides were allowed to pause the pump for care tasks, although she also acknowledged that only nurses were supposed to handle the pump. The CNA did not immediately notify the nurse after the intervention. Interviews with nursing staff and the director of nursing (DON) confirmed that only nurses were permitted to operate the tube feeding pump, and CNAs were expected to call for nurse assistance when care involving the pump was needed. Facility policy and recent in-service training reinforced this expectation, specifying that CNAs should not touch the pump except in emergencies and must notify a nurse for all G-tube related care. The CNA had signed documentation acknowledging this policy, but the incident demonstrated a failure to follow established procedures, resulting in a deficiency related to the care and management of residents with feeding tubes.
Improper Disposal of Garbage and Refuse at Facility Dumpsters
Penalty
Summary
The facility failed to properly dispose of garbage and refuse for both dumpsters located outside the building. During an observation, both dumpster lids were found open, despite the dumpsters not being full, and various items including disposable gloves, a mask, a bag of garbage, a tin can, and papers were observed on the ground next to the dumpsters. Staff interviews confirmed that it was the responsibility of all staff using the dumpsters to ensure the lids were closed and that trash was placed inside the containers, not left on the ground. The Dietary Manager, Housekeeping Manager, and Administrator all acknowledged that the dumpster lids should remain closed at all times and that staff are trained to dispose of trash properly. However, the observation revealed that these procedures were not consistently followed. Additionally, the facility was unable to provide a policy on garbage and refuse disposal by the time of the survey exit.
Medication Administration Error Due to Cart Mix-Up
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident. During a medication administration, a medication aide (MA K) attempted to give Hydrochlorothiazide, a medication intended for another resident, to a resident who was prescribed Hydralazine for hypertension. This error was identified when a surveyor intervened and asked MA K to verify the medication, revealing that the wrong medication had been prepared due to a mix-up in the medication cart. The resident involved was a female with a history of hyperkalemia, hypertension, and pulmonary heart disease, who required assistance with activities of daily living due to moderate cognitive impairment. The resident's care plan included the administration of Hydralazine to manage her blood pressure. The Director of Nursing (DON) confirmed that the nursing staff should adhere to the rights of medication administration, which includes verifying the correct patient and medication. The facility's Medication Management policy also emphasizes minimizing medication errors by following these rights.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents, as observed during a survey. The enteral feeding pumps and poles used by the residents were found to be dirty on multiple occasions, with a rust-colored substance present on the wheelbases. Additionally, the rooms of the residents had peeling and missing paint, and the bedside tables were not well-maintained, with one table having a white substance adhered to it. These conditions were observed over several days, indicating a lack of regular cleaning and maintenance. Resident #27, a woman with multiple diagnoses including dementia, contractures, and GERD, was observed to be dependent on a feeding tube for nutrition. Her room had peeling paint and the feeding tube apparatus was dirty. Similarly, Resident #41, who also had significant health issues such as osteomyelitis and disorientation, was found in a room with a dirty feeding tube apparatus and a poorly maintained bedside table. Both residents were unable to communicate effectively due to cognitive impairments, which may have contributed to the oversight of their environmental conditions. Interviews with the Director of Nursing (DON) and the Administrator revealed that there was no clear policy for cleaning the feeding tube poles, although the DON acknowledged the importance of keeping them clean to prevent infection. The Administrator admitted that the rooms were not homelike and that staff had been trained to address such issues. However, the facility's Guardian Angel Weekly Round Checklist, which was supposed to identify and address these concerns, did not seem to be effectively implemented, as the issues in the residents' rooms were not resolved.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for four residents. Resident #29's care plan did not include her most recent fall on March 14, 2024, despite a progress note from an LVN documenting the incident. The resident, who has a history of dementia and other medical conditions, was found alongside her bed in a high Fowler's position without signs of discomfort or injury. The care plan only reflected a previous fall from December 15, 2023, and did not account for the recent event. Resident #40's care plan was not updated to include her hospice care and current UTI/antibiotic treatment. The resident, who has severe cognitive impairment and a life expectancy of less than six months, was receiving hospice care as per physician's orders. However, the care plan only mentioned advanced care planning and did not reflect the hospice admission or the antibiotic treatment for her UTI, despite these being documented in the physician's orders and progress notes. Resident #57's care plan did not reflect her updated diet, which had been changed to pureed with large portions and included a nutritional supplement. The resident, who has severe cognitive impairment and a history of significant weight loss, had her diet downgraded following a choking incident. The dietary manager's recommendations and physician's orders for the new diet were not incorporated into the care plan. Similarly, Resident #41's care plan did not include the updated PEG tube feeding rate, despite physician's orders and observations indicating the current feeding regimen.
Failure to Conduct PASARR Level II Evaluations
Penalty
Summary
The facility failed to refer two residents with newly evident or possible serious mental disorders for a Level II PASARR evaluation upon a significant change in status assessment. Resident #1, a woman with diagnoses including major depressive disorder (MDD), intermittent explosive disorder, and psychotic disorder with delusions, was not referred to the appropriate state-designated authority for a Level II PASARR review. Her PASRR form, dated 10/24/2022, was negative for mental illness, intellectual disability, or developmental disability, despite her significant mental health diagnoses. Similarly, Resident #72, who had diagnoses of Alzheimer's disease, schizoaffective disorder, and major depressive disorder, was not referred for a Level II PASARR review. Her initial PASRR Level 1 Screening performed on 9/1/23 incorrectly indicated no evidence of mental illness, despite her history and current treatment for schizoaffective disorder and depression. The resident's care plan and physician's orders documented her mental health conditions and the medications prescribed for their management. Interviews with facility staff, including the MDS Nurse and the Director of Nursing (DON), revealed a lack of proper follow-up on PASRR documentation and an absence of a specific facility policy related to PASRR. The MDS Nurse acknowledged that a follow-up PASRR should have been completed for Resident #1, and the DON confirmed that Resident #1's PASRR should have been noted as positive due to her diagnoses. The facility relied on RAI policies from CMS but did not have a specific PASRR policy, which contributed to the oversight.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN D, who did not adhere to the required Enhanced Barrier Precautions while administering medications to a resident through a PEG tube. The resident, a female with multiple complex medical conditions including multiple sclerosis, dysphagia, and functional quadriplegia, was on Enhanced Barrier Precautions due to her use of a PEG tube for nutrition. Despite the presence of a precaution sign on the resident's door, LVN D entered the room and administered medication with only gloves, neglecting to wear a gown as required. The resident's medical history included severe cognitive impairment and dependency on others for all activities of daily living, as noted in her Admission MDS assessment. She was receiving a significant portion of her nutrition and fluid intake through the PEG tube. The facility's policy on Enhanced Barrier Precautions mandates the use of gowns and gloves during high-contact resident care activities, such as medication administration through a feeding tube, to prevent cross-contamination and the spread of infections. The Director of Nursing confirmed that the Enhanced Barrier Precautions were a standing protocol for residents with indwelling medical devices or wounds, and that staff were expected to don appropriate PPE during care activities. The failure to follow these precautions was acknowledged by LVN D, who admitted forgetting to wear the required PPE, thereby risking contamination to both herself and the resident. The facility's policies emphasize the importance of using transmission-based precautions in addition to standard precautions to protect against multidrug-resistant organisms and other infectious agents.
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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) |
|---|---|---|---|---|
| East View Healthcare | 1.2 mi | — | 8 | 0 |
| Cascades At Jacinto Rehab Lp | 5.6 mi | — | 14 | 1 |
| St James House Of Baytown | 9.3 mi | — | 3 | 0 |
| Fall Creek Rehabilitation And Healthcare Center | 9.7 mi | — | 2 | 0 |
| Paradigm At Faith Memorial | 9.9 mi | — | 8 | 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 August 2026) and official state health department websites.