Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Heights Of North Houston during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
A resident with severe cognitive impairment and multiple pressure injuries and skin wounds was care planned and ordered for Enhanced Barrier Precautions (EBP), requiring staff to wear gown and gloves during high-contact care such as incontinent care. EBP signage was posted outside the room, and facility policy specified gown and glove use for activities including changing briefs and providing hygiene for residents with wounds. A CNA was observed completing incontinent care for the resident while not wearing a gown, despite acknowledging that the door signage indicated PPE was needed and that not wearing PPE posed an infection risk. An LVN and the DON both stated that PPE was required for this resident due to her wounds and that staff had access to the care plan and signage indicating PPE requirements.
A resident with severe cognitive impairment and multiple medical conditions received controlled substances, including Morphine and ABH cream, but the facility failed to consistently document their administration on the MAR and controlled drug logs. Nursing staff admitted to forgetting to record doses, and there was no established process to reconcile these records, resulting in incomplete and inaccurate tracking of controlled medications.
Surveyors found that several resident bathrooms were not kept clean or homelike, with yellow stains on toilets and toilet seats, and peeling tread tape on a bathroom floor. Housekeeping staff cited limitations with cleaning chemicals and hard water as contributing factors, while maintenance staff acknowledged missed issues during audits and the need for toilet seat replacement.
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for one resident. The resident was an elderly female with severe cognitive impairment, admitted with diagnoses including unspecified dementia, hypertension, and major depressive disorder. Her admission MDS documented dependence on staff for all major mobility and transfer activities, and she was coded as having an unstageable pressure injury upon admission. Her care plan, revised in March, identified multiple skin issues, including left and right heel deep tissue injuries (DTIs), a sacral pressure wound, a bruise/discoloration/open blister to the right knee, a left heel ulcer pressure injury, and a right bunion DTI. Based on these wounds, the resident was care planned for EBP, requiring staff to use gown and gloves during high-contact resident care activities. Physician orders for the resident specified Enhanced Barrier Precautions every shift, stating that staff must use gowns and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. The facility’s EBP policy, revised in March, required targeted gown and glove use in addition to standard precautions during high-contact resident care activities, including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, and wound care. The policy further stated that EBPs are indicated for residents with wounds and/or indwelling medical devices, regardless of MDRO colonization status. EBP signage was posted outside the resident’s room to indicate the need for PPE. During an observation, the surveyor approached the resident’s room while the door was open and the curtain drawn, and CNA J stepped out, stating she was performing resident care. CNA J was observed wearing black scrubs without a gown, despite EBP signage outside the room, and had just completed incontinent care for the resident. In a subsequent interview, CNA J acknowledged that the signage indicated PPE was needed when providing care but stated she was unsure whether it applied to the resident or her roommate and reported she had never worn PPE when providing care to this resident, only to the roommate. She was unsure whether the resident had wounds and stated that the risk of not wearing PPE was infection. In contrast, LVN K, assigned to the hall, stated that PPE was required when providing direct care to the resident because she had wounds and noted that CNAs had access to the resident’s plan of care in the electronic health record and to room signage indicating PPE requirements. The DON stated her expectation was that PPE be worn when residents require it and identified infection as the risk when it is not used.
Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to maintain an established system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation. Specifically, there were multiple instances where documentation of controlled substances, including Morphine and ABH cream, was missing from the Medication Administration Record (MAR) and the Controlled Drug Receipt/Disposition Forms for a resident with significant cognitive impairment and multiple comorbidities. The discrepancies included missing entries for both the administration and disposition of these medications across several dates in April and May. The resident involved was an elderly female with diagnoses including dementia, Alzheimer's disease, generalized anxiety disorder, and was receiving palliative care. She required substantial assistance with activities of daily living and was on several psychotropic and pain medications, including controlled substances. Physician orders for Morphine and ABH cream were present, but the MARs and controlled drug logs did not consistently reflect administration as ordered. For example, there were documented administrations on the MAR that were not recorded on the controlled drug logs, and vice versa, as well as missing documentation altogether for certain dates and times. Interviews with nursing staff revealed that medications were likely administered but not documented due to forgetfulness or the challenging behavior of the resident. Staff admitted to omitting documentation on both the MAR and controlled drug logs, and there was no established procedure in place at the time to routinely reconcile these records. The facility's own policies required accurate and timely documentation of controlled substances, but these were not followed, resulting in incomplete records and the inability to accurately account for all controlled drugs administered to the resident.
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in three of four resident bathrooms reviewed. Specifically, toilets and toilet seats in several rooms had visible yellow stains, and the bathroom floor in one room was covered with black tread tape that was peeling and no longer intact. These conditions were directly observed by surveyors on multiple occasions, with yellow staining present on toilet seats and in toilet bowls, and the tread tape on the floor was noted to be peeling and not providing its intended function. Interviews with the Housekeeping Regional Supervisor and the Maintenance Director revealed that the contracted housekeeping company used less potent cleaning chemicals, which they attributed to the persistent stains, and that hard water contributed to discoloration. The Maintenance Director acknowledged that some toilet seats needed replacement and that a recent audit may have missed these issues. The tread tape had been installed at a family member's request and was only present in one bathroom, but it was not being properly maintained. The housekeeping staff typically notified maintenance when stronger cleaning was needed, but the process was not consistently effective in preventing or addressing the deficiencies observed.
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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 Cypress Station | 0.3 mi | — | 3 | 0 |
| Paradigm Northwest | 0.7 mi | — | 16 | 0 |
| Villa Toscana At Cypress Woods | 2.8 mi | — | 13 | 0 |
| The Village At Gleannloch Farms | 5.3 mi | — | 4 | 0 |
| Avir At Veterans Memorial | 7.4 mi | — | 20 | 3 |
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