Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
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 West Janisch Health Care Center during CMS and state inspections, most recent first.
A fire occurred in one hall, resulting in the death of a resident who was dependent on staff for all care. Staff were unable to access the hall for several minutes due to locked doors triggered by the fire alarm, delaying emergency response. After the fire was extinguished, staff did not assess or render aid to the affected resident, and some residents were left unattended or not evaluated after evacuation. Staff had not been trained on emergency response for severe burns, and the facility had known about the door access issue for months without resolving it.
Staff failed to promptly extinguish a fire involving a resident, used a non-fire retardant blanket that worsened the flames, and did not assess or render aid after the fire was out, resulting in the resident's death. Multiple residents were left in their rooms during the fire, leading to prolonged smoke exposure, and the facility did not follow its fire safety plan. The affected resident had significant mobility limitations and was dependent on staff for care.
The facility did not follow its approved menus for resident meals, making undocumented substitutions without registered dietitian approval and failing to post menus as required. A resident received a meal missing a side, and desserts were changed due to budget constraints, with no evidence of proper oversight. Staff interviews confirmed that menu changes were made based on preferences and cost, but without the necessary documentation or approval, placing residents at risk of inadequate nutrition.
A fire in a resident room resulted in one fatality and smoke exposure to 22 residents. The administrator did not report the incident to the State Survey Agency within the required two-hour window. Staff extinguished the fire and evacuated residents, but the resident who died did not receive an immediate nursing assessment after the fire. The deceased had significant medical needs and was a compliant smoker. Other residents in the affected area had cognitive and physical impairments and were also exposed to smoke.
Two residents' MDS assessments were found to be inaccurate: one resident with left-sided paralysis and total dependence for ADLs was not documented as having functional limitations or paralysis, and another resident with severe cognitive impairment and a history of wandering was not initially documented as exhibiting wandering behavior, despite frequent observations and care planning for such. Staff interviews and record reviews confirmed these discrepancies, and responsible staff acknowledged the errors as oversights.
A resident's care plan was not updated by the interdisciplinary team to reflect the removal of a urinary catheter and the resolution of a pressure ulcer, despite medical records and staff confirming these changes. The care plan continued to list both issues as active until surveyor intervention, and staff interviews revealed confusion about who was responsible for updating care plans.
Two residents at high risk for falls did not have fall mats included in their care plans, despite experiencing falls. Staff interviews highlighted the importance of listing such interventions for resident safety, and the DON acknowledged the oversight.
A facility failed to securely store medications, as 18 loose pills were found in a medication cart assigned to an LVN. The LVN was responsible for maintaining the cart's cleanliness and acknowledged the risks of loose pills, such as allergic reactions or residents consuming them. The DON confirmed the responsibility of checking carts and the potential harm from loose pills, while the Regional Nurse Consultant noted packaging issues.
Failure to Protect Residents During Fire and Inadequate Emergency Response
Penalty
Summary
The facility failed to protect residents from neglect and did not ensure their right to be free from abuse, neglect, and exploitation, as evidenced by a fire incident on the 400 Hall that resulted in the death of a resident. Staff were unable to timely extinguish the fire and did not assess or render aid to the affected resident after the fire was put out. The resident, who had a history of stroke with left-sided weakness, was dependent on staff for all activities of daily living and required a mechanical lift with two staff for transfers. She was found with severe burns and expired in the facility immediately after the fire. The medical examiner confirmed that the resident had significant burns and soot in her airway, indicating she was breathing during the fire. The facility was aware for over six months that, upon activation of the fire alarm system, control access doors would lock and prevent staff from entering the 400 Hall without a code. During the fire, staff were unable to access the hall for three minutes, leaving only one CNA on the hall with the residents. Security footage and interviews confirmed that staff struggled to open the doors, attempted to enter codes, and were delayed in providing assistance to residents, including the one who was on fire. Some residents were left unattended or not assessed after evacuation, and staff did not know the unlocking mechanisms for the controlled access doors during the emergency. Interviews with staff and the DON revealed that prior to the incident, staff had not been trained on how to respond to residents with severe burns, and no assessment or aid was rendered to the resident after the fire was extinguished. The DON acknowledged that staff should have assessed the resident but did not do so. The medical director stated that staff should have monitored vital signs and breathing and stayed with the resident until EMS arrived. The lack of timely intervention and assessment contributed to the severity of the incident, and the facility's failures affected all residents on the 400 Hall during the emergency.
Failure to Provide Timely Fire Response and Resident Assessment During Fire Incident
Penalty
Summary
Facility staff failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals, as evidenced by a fire incident involving a resident who was engulfed in flames. Staff did not immediately extinguish the fire using a fire extinguisher and instead used a non-fire retardant blanket, which worsened the fire. After the fire was extinguished, staff did not assess or render aid to the resident, who subsequently expired in the facility. The resident had a history of stroke with left-sided weakness, was dependent on staff for mobility and transfers, and was a known smoker with a care plan addressing smoking-related risks. The last clinical assessment for this resident was completed prior to the incident, and no assessment was documented after the fire. During the fire, staff failed to follow the facility's fire safety plan for evacuating residents from the affected hall. Multiple residents were left in their rooms during the fire, resulting in prolonged exposure to smoke. Security footage and fire department reports confirmed that staff response was delayed and uncoordinated, with some residents being evacuated only after several minutes had passed. The fire department found that some residents were sheltered in place due to smoke conditions, and the fire was confined to the bed of the resident who expired. The fire alarm system operated as intended, alerting staff and prompting a response, but the evacuation process was not executed according to established protocols. Interviews with the facility's Medical Director and DON revealed that staff were not trained on how to respond to residents with severe burns prior to the incident. The DON acknowledged that no assessment was performed on the resident after the fire, which was a deviation from professional standards of practice. The Medical Examiner reported that the deceased resident suffered from second and third-degree burns, with significant charring and soot deposition in the airway, indicating the resident was breathing during the fire. The report also documented deficiencies in care and services for multiple other residents on the affected hall, including failures to provide assistance with mobility and ADLs as outlined in their care plans.
Failure to Follow and Document Approved Menus for Resident Meals
Penalty
Summary
The facility failed to ensure that planned menus were followed and prepared according to the weekly menu for six out of six meals reviewed. Observations, interviews, and record reviews revealed that the posted and served meals did not match the facility's approved weekly menu on multiple occasions. For example, the posted menu and the meals served for lunch and dinner on several days differed from the planned menu, with substitutions made without proper documentation or approval from the registered dietitian. Residents were served alternate items, such as a hamburger without a side, and desserts were substituted due to cost constraints, with no evidence of dietitian approval for these changes. Interviews with staff indicated that the Dietary Director made menu substitutions based on resident preferences and budget limitations, but was unable to provide documentation of dietitian approval for these changes. The Registered Dietitian confirmed that she had not approved the menu changes and that the process required a substitution log to be completed and signed off by the dietitian, which was not done. The Regional Registered Dietitian also stated that while resident feedback is considered, substitutions must maintain nutritional equivalence and be properly documented and approved. The facility's policy requires menus to be prepared in advance, posted in accessible areas, followed as posted, and any deviations to be approved by the dietitian. However, the investigation found that menus were not consistently posted, substitutions were made without proper approval, and documentation of these changes was lacking. This failure placed residents at risk of not receiving meals adequate to meet their nutritional needs.
Failure to Timely Report Fire Incident and Resident Death to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the administrator and appropriate authorities as required. Specifically, the administrator did not report a fire incident in the 400 Hall, which resulted in the exposure of 22 residents to smoke and the death of one resident, to the State Survey Agency within the mandated two-hour timeframe. The incident was instead reported several hours later via email, despite the administrator being informed of the fire and fatality shortly after the event occurred. This delay in reporting was confirmed through record review of the facility's reporting system and interviews with staff. The fire occurred in a resident room and was discovered by a CNA, who observed a resident on fire. Staff responded by extinguishing the fire, contacting 911, and relocating residents from the affected area. Security footage showed staff attempting to evacuate residents, with some delays caused by locked doors and confusion during the evacuation process. The fire department and EMTs arrived on the scene, and one resident was pronounced deceased. The deceased resident had significant medical needs, including total dependence for mobility and ADLs, a history of stroke with left-sided weakness, and was a known smoker who was compliant with the facility's smoking policy. The cause of the fire remained undetermined at the time of the report. Interviews and documentation revealed that after the fire, the resident who suffered fatal burns did not receive an immediate assessment or medical intervention from nursing staff prior to the arrival of EMS. The DON acknowledged that staff were not trained on how to respond to severe burns prior to the incident and confirmed that no assessment was performed on the resident after the fire was extinguished. The medical examiner later confirmed that the resident had been breathing while on fire, with 26% of her body surface burned. Other residents in the affected hall had significant cognitive and physical impairments, requiring various levels of assistance for mobility and ADLs, and were also exposed to smoke during the incident.
Failure to Accurately Document Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of two residents. For one resident with a history of stroke, diabetes, depression, and mild cognitive impairment, the quarterly Minimum Data Set (MDS) assessment did not document left-sided hemiplegia and hemiparesis as a functional limitation in range of motion or as a diagnosis, despite multiple records and staff interviews confirming total dependence for activities of daily living (ADLs), use of a mechanical lift, and paralysis on the left side. The care plan, transfer records, and staff interviews consistently described the resident as bed- or wheelchair-bound, requiring maximal assistance, yet the MDS failed to capture these significant limitations. For another resident with severe cognitive impairment and a diagnosis of unspecified dementia, the quarterly MDS assessment did not initially document wandering behavior in Section E, even though the resident was observed walking throughout multiple hallways and had a documented history of wandering. The resident was care planned for use of a wander guard bracelet, had a daily order for a wander device alarm, and was visually checked for the device every shift. Staff interviews and observations confirmed frequent wandering behavior, but the MDS did not reflect this until it was later modified. The deficiencies were identified through interviews, observations, and record reviews, which revealed inconsistencies between the residents' actual conditions and the information documented in their MDS assessments. Staff responsible for completing the MDS acknowledged the errors and attributed them to oversight, resulting in assessments that did not accurately represent the residents' functional limitations or behaviors as required by federal regulations.
Failure to Timely Update Care Plan After Catheter Removal and Wound Resolution
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by an interdisciplinary team for one resident. Specifically, the care plan was not updated to reflect the removal of a urinary catheter, which had an order for removal, nor was it revised when a pressure ulcer wound resolved and the related order was discontinued. Documentation showed that the resident's care plan continued to list an indwelling catheter and an active pressure ulcer after both had been resolved or removed, as confirmed by medical records, medication administration records, and staff interviews. Multiple staff members, including nurses and certified nursing assistants, confirmed that the resident no longer had a catheter or an active pressure ulcer, but the care plan was not updated until after surveyor intervention. The resident involved was an older male with a history of schizophrenia and moderate cognitive impairment. Medical records indicated that the Foley catheter was removed and the pressure ulcer had healed, yet the care plan still reflected these resolved issues. Staff interviews revealed confusion and lack of clarity regarding responsibility for updating care plans, with various staff members indicating that the DON, ADON, or wound care nurse might be responsible. The facility's policy required the interdisciplinary team to review and revise care plans after each assessment, but this was not followed in this case.
Failure to Include Fall Mats in Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for two residents identified as high risk for falls. Resident #34, a female with hemiplegia and hemiparesis following a cerebral infarction, experienced three falls over six months. Despite being care planned for falls, her care plan did not include the intervention of a fall mat, which was observed next to her bed. Similarly, Resident #28, diagnosed with dementia and metabolic encephalopathy, had a fall recorded but her care plan also lacked the intervention of a fall mat, even though she had previously fallen onto one. Interviews with staff revealed that the absence of fall mats in the care plans could lead to increased risk of injury for these residents. A CNA and an LVN both noted the necessity of fall mats for these residents, with the LVN highlighting the importance of listing such interventions in care plans for new staff awareness. The DON acknowledged the responsibility of updating care plans with new interventions and confirmed that fall mats should have been included to prevent potential injuries.
Medication Storage Deficiency Due to Loose Pills in Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by the presence of 18 loose pills in a medication cart assigned to an LVN. These pills were found at the bottom of a drawer beneath tightly packed medication blister cards. The LVN, who was responsible for administering medications and maintaining the cleanliness of the cart, acknowledged the presence of the loose pills and the potential risks associated with them, such as allergic reactions or residents inadvertently consuming them. The Director of Nursing (DON) confirmed that the charge nurses, DON, and ADON were responsible for checking medication carts. The DON acknowledged the risks posed by loose pills, including the possibility of residents experiencing side effects or harm if they accessed the pills. The Regional Nurse Consultant noted that pills might fall out of blister cards due to pharmacy packaging. The facility's policy mandates that all medications be stored securely in locked compartments, but this was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 585 citations issued within 25 miles in the last 12 months — including the 55 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caraday Of Houston | 1.6 mi | — | 1 | 0 |
| Highland Park Care Center | 2 mi | — | 0 | 0 |
| Ashford Gardens | 2.1 mi | — | 5 | 0 |
| Houston Heights Nursing And Rehabilitation Center | 3.5 mi | — | 2 | 0 |
| Spring Branch Transitional Care Center | 5.7 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for West Janisch Health Care Center.
100% money-back within 48 hours.
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.