Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Eagle Crest Rapid Recovery during CMS and state inspections, most recent first.
A resident with advanced dementia, anxiety, depression, and significant cognitive impairment became physically aggressive toward staff during a transfer, hitting and scratching a CNA and an LVN. During this period, a CNA spoke to the resident in a rude and demeaning manner on more than one occasion, which was identified as verbal and emotional abuse and a violation of the resident’s right to dignity and respect. The NP later reported not being informed of the specific abusive comments or the resident’s sensitivity to certain language, despite expecting detailed information on abuse allegations and behavior issues. These actions occurred despite facility policies requiring protection from abuse and respectful, dignified treatment of all residents.
A resident with severe cognitive impairment, dementia, anxiety, and depression became physically aggressive during transfers, striking an LVN and scratching both an LVN and a CNA. Audio/video later captured a CNA telling the resident, "You do not hit anyone in the face. Ugly, ugly, ugly," after which the resident was heard screaming; the resident’s representative later found the resident crying and repeatedly stating she was not ugly. Although the NP later assessed the resident related to an abuse allegation, the MD reported he was never informed of the allegation, and the NP stated she was not told the specific details of the verbal abuse or the resident’s sensitivity to the word used. This sequence of events shows the facility did not immediately consult the physician or fully inform the resident representative about a significant change and abuse allegation, contrary to its own condition-change reporting policy.
A resident with severe cognitive impairment, total dependence for toileting, and continuous bladder and bowel incontinence was found with a heavily urine-soiled brief and strong urine odor after not receiving incontinent care for over four hours, despite a care plan requiring check-and-change as needed. The assigned CNA reported the last care was provided in the morning, then assisted with meals and went on break without checking the resident beforehand or arranging clear coverage, and the RN on duty did not recall being informed of the break. The DON stated residents should be checked for incontinence every two hours and that the nurse in charge and CNAs are responsible for ensuring timely incontinent care and communication around breaks, while facility documents showed an incontinence care policy and peri-care training materials.
A resident with severe cognitive impairment and total dependence for toileting was found in a heavily urine-soiled brief with a strong odor after more than four hours without incontinence care, despite a care plan and expectation for checks and changes about every two hours. The assigned CNA reported last providing care in the late morning, then assisted with meals and went on break without re-checking the resident or confirming relief coverage, while the RN on duty did not recall being notified of the CNA’s break. During observed incontinence care, the CNA cleaned the resident’s perineal area from back to front rather than front to back, contrary to facility training materials, although the resident’s skin was intact at the time. The DON stated residents should be checked every two hours for incontinence and that the nurse in charge is responsible for ensuring timely incontinence care.
A resident with multiple serious medical conditions had a documented DNR order and a care plan intervention requiring staff to check DNR status before calling a code. During rounding, a nurse found the resident gasping, sweating, and then unresponsive, and an LVN called a code and initiated CPR and other life-saving measures without first verifying code status. EMS continued life-saving efforts until the resident’s active DNR was later located and confirmed, and interviews and records showed this action was contrary to facility policy requiring verification of DNR status before initiating life-saving measures.
A resident's insulin was left unattended at her bedside by an LVN, contrary to the facility's policy requiring medications to be secured and locked. The resident, who had Type 2 diabetes and intact cognition, did not notice the medication. The LVN acknowledged the mistake and the risk involved, while the facility's policy emphasized secure storage of medications.
A resident with multiple health conditions and a high fall risk rolled off the bed during incontinent care due to inadequate supervision and assistance. The resident required extensive assistance for bed mobility, but only one CNA was present, contrary to the care plan. The CNA reported the resident was rocking and did not hold her weight, leading to the fall. The resident was sent to the hospital for evaluation, where no abnormalities were found.
Verbal and Emotional Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from abuse, neglect, and to be treated with dignity and respect. The resident was an elderly female with multiple diagnoses including Alzheimer’s disease, dementia with severe cognitive impairment (BIMS score of 02), generalized anxiety disorder, major depressive disorder, psychotic and mood disturbances, a history of transient ischemic attack, muscle weakness, difficulty walking, dysphagia, and a cognitive communication deficit. These conditions contributed to significant cognitive and functional limitations. On the date of the incident, the resident was being assisted with a transfer from bed to wheelchair by CNA A and LVN A when she became physically aggressive, hitting both staff in the face, pulling LVN A’s hair, and digging her nails into both staff members’ arms. Staff attempts at redirection were documented as unsuccessful. During this same period, CNA A spoke to the resident in a rude manner on at least two occasions, which the facility and surveyors identified as verbal and emotional abuse and a violation of the resident’s right to dignity and respect. The report states that on one date CNA A verbally and emotionally abused the resident by speaking rudely to her, and on another date CNA A again spoke rudely to the resident, failing to treat her with dignity and respect. The report further notes that the resident had anxiety, memory issues, and a pattern of lashing out physically toward staff when feeling scared or having difficulty remembering people, places, and events throughout the day, making the manner of staff communication particularly significant. The NP who evaluated the resident after the abuse allegation reported that she had not been informed that staff had commented to the resident that she or her behavior was “ugly,” nor that the resident had issues with the use of the word “ugly” from childhood. The NP stated it was her expectation to be informed of the specifics of abuse allegations and behavior issues so she could address the resident’s behavior concerns more specifically. The facility’s own policies on Abuse Prevention and Resident Rights required that residents be protected from abuse by anyone and be treated with respect and dignity in an environment that promotes or enhances quality of life. Despite these policies, CNA A’s rude and demeaning communication toward the resident on the identified dates constituted the abusive and undignified treatment that led to the cited deficiency. The noncompliance was identified as past noncompliance, beginning on 02/18/2024 and ending on 02/23/2026, and involved at least one resident who was subjected to rude, emotionally harmful communication by a CNA. The survey findings specify that this failure could place residents at risk of abuse, mental anguish, and fearfulness. The documentation and interviews collectively show that, although the resident had significant cognitive and behavioral issues and sometimes became physically aggressive during care, staff were still required by policy and regulation to interact with her in a respectful, compassionate manner, which did not occur when CNA A spoke to her rudely and in a way characterized as demeaning and emotionally abusive.
Failure to Notify Physician and Representative of Abuse Allegation and Significant Change
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident representative when there was a significant change in condition related to an abuse allegation. The resident was an elderly female with Alzheimer’s disease, dementia with severe cognitive impairment (BIMS score of 02), generalized anxiety disorder, major depressive disorder, and other mood and psychotic disturbances. On the date of the incident, progress notes documented that the resident became physically aggressive during a bed-to-wheelchair transfer, hitting an LVN in the face, pulling the LVN’s hair, and scratching both the LVN and a CNA. A subsequent behavior note documented that the resident refused morning medications and again became physically aggressive during transfer attempts, with staff attempting but failing to redirect her behavior. Audio/video recordings from the resident’s room later showed that after the transfer, when the LVN had left the room, the CNA told the resident, “You do not hit anyone in the face. Ugly, ugly, ugly,” in reference to the resident’s behavior, while the resident was heard screaming. The ADM and DON confirmed that the CNA used the phrase “ugly, ugly, ugly” toward the resident and that this was hurtful to the resident due to a past history of being called ugly as a child. The resident’s representative reported that on the same day, the resident was crying and repeatedly saying, “I am not ugly,” and that she had to reassure the resident that she was not ugly. The representative also stated that the resident had pain when moved due to metal in various parts of her body and placed signage on the door asking staff to be careful when moving the resident. Despite the abuse allegation and the emotional impact on the resident, the resident’s physician stated he was not informed of the allegation and was unaware of the incident. The NP reported that she assessed the resident several days later related to an abuse allegation made on the date of the incident but was not informed that staff had called the resident or her behavior “ugly,” nor that the resident had a specific sensitivity to that word from childhood. The NP stated it was her expectation to be informed of the specifics of abuse allegations and behavior issues in order to assess and treat the resident appropriately. The facility’s undated policy on condition change required observing, recording, and reporting any condition change to the physician so proper treatment could be implemented, but the MD confirmed that the abuse allegation involving this resident was not reported to him immediately as he expected.
Failure to Provide Timely Incontinent Care and Personal Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and necessary services to maintain personal hygiene for one resident who was totally dependent on staff for toileting and was always incontinent of bladder and bowel. The resident, an elderly female with severe cognitive impairment (BIMS score of 4) and multiple neurologic and medical conditions including aphasia, hemiplegia/hemiparesis, and a history of severe sepsis, had a care plan intervention for bladder and bowel incontinence that included checking and changing as required. During an observation of incontinent care in the afternoon, surveyors noted a strong odor of urine when the resident’s brief was removed, and the brief was heavily soiled with urine, although the skin remained intact without redness or rash. CNA A reported that the last incontinent care provided to this resident had been at 10:00 a.m., and that she usually checked and changed the resident every two hours. CNA A stated she had been assisting residents in the dining room with meals and then went on break, telling the nurse but not checking the resident for incontinence before leaving and not arranging specific coverage with another CNA. She did not answer when asked why she failed to check the resident before her break and said she did not know who was supposed to relieve her. RN C stated she did not recall being told that CNA A was going on break and did not know which CNA was covering. The DON stated residents should be checked for incontinence every two hours, that failure to do so placed residents at risk, and that the nurse in charge is responsible for ensuring timely incontinent care, with CNAs expected to notify other CNAs and the charge nurse before going on break and to check residents’ needs, including incontinence, prior to leaving. Facility documents included an incontinence care policy and a peri-care training form, but the DON reported there was no specific policy on female incontinence.
Failure to Provide Timely and Proper Incontinence Care and Peri-Care Technique
Penalty
Summary
The facility failed to provide appropriate incontinence care and maintain continence for a resident who was always incontinent of bladder and bowel, as documented on the quarterly MDS. The resident, an elderly female with severe cognitive impairment (BIMS score of 4) and multiple neurologic and medical conditions including aphasia, hemiplegia/hemiparesis, and severe sepsis, was care planned for bladder and bowel incontinence related to impaired mobility, with an intervention to check and change as required for incontinence. On observation, when staff removed the resident’s brief in the afternoon, there was a strong odor of urine and the brief was heavily soiled, despite CNA A stating that the last incontinence care provided had been at 10:00 a.m. and that care was usually provided every two hours. CNA A reported assisting residents in the dining room and then going on break without checking the resident for incontinence prior to the break and without knowing which CNA was to relieve her, while the RN on duty did not recall being informed of the break or knowing who was covering for CNA A. During the observed incontinence care, CNA A did not follow proper peri-care technique for a female resident. After the resident was repositioned to her right side, CNA A cleaned the perineal area from back to front using the same disposable washcloth, then continued to clean the buttocks in the same back-to-front manner with a new washcloth, contrary to the facility’s training form that directed washing the genital area from front to back. The resident’s skin was intact with no redness or rash at the time of observation. The DON stated that residents should be checked for incontinence every two hours and that failure to do so placed residents at risk for skin breakdown, urinary tract infections, and moisture-associated dermatitis, and also stated that CNAs are expected to notify other CNAs and the charge nurse when going on break and to ensure residents’ needs, including incontinence care, are met before leaving. The facility’s incontinence care policy emphasized keeping skin clean, dry, and free of irritation and odor, and preventing skin breakdown and infection.
Failure to Verify and Honor Resident DNR Prior to Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) order by not verifying code status before initiating life-saving measures. The resident was an older male with multiple significant diagnoses, including cerebral infarction, muscle weakness, hyperlipidemia, type 2 diabetes without complications, quadriplegia, acute posthemorrhagic anemia, and hypotension. His care plan documented that he was DNR, and an intervention required staff to check the resident’s file for DNR status before calling a code. During routine rounding, a nurse observed the resident gasping for air, sweating profusely, and then becoming unresponsive. A code was called, life-saving measures were initiated, and 911 was contacted. Cardiopulmonary resuscitation (CPR) and other life-saving interventions were provided by LVN A and then continued by emergency medical services (EMS) upon their arrival, before the resident’s DNR documentation was located and confirmed as active. Interviews and record reviews showed that facility policy required staff to determine whether a resident had a DNR in place before taking any life-saving measures. The Administrator, ADON, and nursing staff stated that the nurse who calls a code is responsible for verifying DNR status prior to initiating CPR, and that failing to do so violates facility policy. The facility’s provider report documented that the nurse on duty failed to comply with the resident’s DNR by calling a code and initiating life-saving measures despite the DNR order being in place.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional principles, as observed with a resident who had Type 2 diabetes mellitus. The resident's insulin was left unattended at her bedside by an LVN, which was against the facility's policy for medication security. The resident, who had an intact cognitive status and required supervision for mobility, did not notice the medication left on her table. This incident was observed during a routine medication administration when the LVN placed the insulin pen on a table approximately five feet from the resident's bed and left it unattended while washing her hands in the bathroom. Interviews with the covering DON and the Administrator revealed that the facility's policy required all medications to be secured and locked to prevent unauthorized access. The LVN admitted to leaving the insulin unattended and acknowledged the risk of the resident accessing the medication. The facility's policy, as reviewed, emphasized the importance of storing drugs and biologicals in locked compartments and maintaining medication storage areas in a safe and sanitary manner. The failure to adhere to these policies posed a risk of drug diversion or accidental ingestion.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who rolled off the bed during incontinent care. The resident, a 64-year-old woman with multiple health conditions including reduced mobility and a high risk for falls, was being assisted by a CNA when the incident occurred. The resident's care plan indicated she required extensive assistance for bed mobility, yet only one CNA was present during the care, contrary to the care plan's requirements. During the incident, the CNA was performing incontinent care and attempted to change the resident's position on the bed. The CNA reported that the resident was rocking and did not hold her weight, which led to the resident rolling off the bed. The bed was at hip height, and the CNA believed the resident was in the middle of the bed, not near the edge. However, the resident fell, hitting her legs on the bedside table, and complained of pain. The resident was subsequently sent to the hospital for evaluation, where no abnormalities were found. Interviews with other CNAs revealed that the resident was considered difficult to work with due to her size and required careful handling during care. It was noted that the resident did not have side rails to hold onto at the time of the fall, which were added later. The facility's DON confirmed that the resident was a one-person assist for bed mobility, but the incident highlighted a lack of adherence to the care plan and insufficient supervision during care, leading to the resident's fall.
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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) |
|---|---|---|---|---|
| Cypress Pointe Health & Wellness | 0.9 mi | — | 12 | 0 |
| Cypress Creek Rehabilitation And Healthcare Center | 2.5 mi | — | 4 | 0 |
| Copperfield Healthcare And Rehabilitation | 2.8 mi | — | 17 | 3 |
| Fallbrook Rehabilitation And Care Center | 3 mi | — | 16 | 3 |
| Park Manor Of Cyfair | 3 mi | — | 0 | 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.