Inspection Reports for Park Manor of Westchase
11910 Richmond Ave., Houston, TX 77082, TX, 77082
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 1
Date: Jun 11, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of baseline care plans for residents within 48 hours of admission.
Findings
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #1, who had a pressure ulcer on the left lateral thigh. The care plan did not address the pressure ulcer with measurable objectives and timeframes, potentially affecting resident care quality.
Deficiencies (1)
Failure to create and implement a comprehensive care plan addressing Resident #1's pressure wound within 48 hours of admission.
Report Facts
Residents affected: 5
Residents affected: 1
Days to complete care plan: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Provided care to Resident #1 and interviewed about care plan and pressure ulcer |
| LVN C | Licensed Vocational Nurse | Provided care to Resident #1 and interviewed about pressure ulcer care and care plan |
| RN A | MDS and Care Plan Coordinator | Completed MDS for Resident #1 and interviewed about care plan completion |
| Wound Care Nurse | Provided wound care to Resident #1 and interviewed about care plan and wound treatment | |
| RN B | Registered Nurse | Interviewed about wound care and care plan completion |
| DON | Director of Nursing | Interviewed about Resident #1's admission, wound care, and care plan |
| Administrator | Interviewed about care plan completion process |
Inspection Report
Routine
Deficiencies: 9
Date: Feb 22, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident dignity, MDS data transmission, activities of daily living assistance, accident prevention, incontinent care, feeding tube care, medication storage, respiratory care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity, failure to transmit MDS data timely, inadequate assistance with activities of daily living, inadequate supervision leading to resident elopement, improper incontinent and catheter care, failure to follow feeding tube protocols, improper medication labeling, incorrect oxygen administration, and lapses in infection prevention and control practices.
Deficiencies (9)
Failure to treat Resident #44 with dignity by exposing his catheter bag in the dining room without privacy.
Failure to transmit encoded, accurate, and complete MDS data to CMS within required timeframes for 2 residents.
Failure to provide necessary assistance with activities of daily living, including personal grooming for Resident #31.
Failure to provide adequate supervision and prevent elopement of Resident #1 who left the facility on pass and did not return.
Failure to ensure appropriate incontinent care and Foley catheter care for Resident #31, including improper placement of Foley bag and inadequate cleaning.
Failure to provide care to prevent complications related to gastrostomy tube for Resident #76, including failure to pause feeding and maintain head elevation during care.
Failure to ensure oxygen administration for Resident #81 was set according to physician orders.
Failure to ensure drugs and biologicals were labeled with resident's name and date opened in medication carts.
Failure to implement an effective infection prevention and control program, including lapses in hand hygiene, PPE use, and cross-contamination prevention for Residents #31, #41, and #76.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts reviewed: 6
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT A | Named in dignity deficiency for Resident #44 | |
| CNA C | Named in incontinent care and infection control deficiencies for Resident #31 | |
| CNA F | Named in feeding tube care and infection control deficiencies for Resident #76 | |
| LVN S | Named in feeding tube care, oxygen administration, and infection control deficiencies | |
| LVN QQ | Named in Foley catheter care deficiency for Resident #41 | |
| CNA AA | Named in Foley catheter care and infection control deficiencies for Resident #41 | |
| Administrator | Named in elopement and infection control deficiencies | |
| DON | Director of Nursing | Named in multiple deficiencies including elopement, infection control, and oxygen administration |
| IP | Infection Preventionist | Named in incontinent care and infection control deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 22, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS system within the required timeframe for residents.
Complaint Details
The complaint investigation found that the facility did not transmit the required Discharge MDS assessments for residents CR #96 and CR #97 within the mandated 14-day period, resulting in noncompliance with CMS regulations. The MDS Coordinator and Administrator confirmed the missed transmissions and the potential negative outcome of noncompliance.
Findings
The facility failed to transmit completed Discharge MDS assessments for 2 out of 3 residents reviewed (CR #96 and CR #97) within 14 days of completion, which could result in denial of services or payment. Interviews confirmed the assessments were missed and not transmitted as required by policy and CMS regulations.
Deficiencies (1)
Failure to transmit completed Discharge MDS assessments for residents CR #96 and CR #97 within 14 days of completion.
Report Facts
Residents reviewed for MDS transmission: 3
Residents with failed MDS transmission: 2
Inspection Report
Routine
Deficiencies: 2
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with infection control and incontinent care protocols, including wound care and use of personal protective equipment (PPE) for residents.
Findings
The facility failed to provide appropriate incontinent care and infection control for residents, including improper hand hygiene by CNA A, failure to clean peri-wound areas by LVN A, and improper use of PPE by staff. These failures placed residents at risk of infections and potential hospitalization.
Deficiencies (2)
Residents who are incontinent of bowel did not receive appropriate treatment and services to prevent urinary tract infections; CNA A did not follow acceptable hand-sanitizing practices during incontinent care for Resident #3.
Facility failed to establish and maintain an infection prevention and control program; CNA A did not use alcohol-based sanitizer between glove changes; LVN A did not clean peri-wound before dressing; LVN A did not remove gown and gloves when leaving and re-entering resident rooms.
Report Facts
Residents reviewed for incontinent care: 7
Wound size Resident #5: 1
Wound size Resident #9: 1.03
BIMS score Resident #3: 10
BIMS score Resident #9: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in findings for improper hand hygiene and incontinent care for Resident #3 |
| LVN A | Licensed Vocational Nurse and Wound Care Nurse | Named in findings for failure to clean peri-wound and improper PPE use during wound care for Residents #5 and #9 |
| DON | Director of Nursing | Provided statements on expected infection control practices and monitoring |
| ICP | Infection Control Preventionist | Provided statements on infection control expectations and staff training |
| Administrator | Facility Administrator | Provided statements on staff retraining for infection control issues |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 31, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with providing a safe, clean, comfortable, and homelike environment for residents, focusing on environmental concerns related to sanitation and safety in resident rooms and restrooms.
Findings
The facility failed to maintain a safe, clean, and sanitary environment for two residents, including unsanitary conditions in Resident #2's restroom and Resident #4's room, which posed risks of infection and safety hazards. Observations and interviews confirmed feces and urine contamination, inadequate cleaning, and lapses in housekeeping and maintenance notification procedures.
Deficiencies (2)
Failed to provide a safe, clean, and sanitary restroom for Resident #2, including feces in the restroom and a backed-up toilet.
Failed to provide a safe, clean, and sanitary resident room for Resident #4, including dried urine on the floor beneath the bed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Interviewed regarding facility cleanliness concerns and corrective actions for Resident #2 and Resident #4's rooms. |
| Central Supply Coordinator | Central Supply Coordinator | Interviewed about housekeeping responsibilities and notification procedures for maintenance issues. |
| DON | Director of Nursing | Interviewed about infection risks and resident behaviors related to toileting and room cleanliness. |
Inspection Report
Routine
Deficiencies: 5
Date: Dec 22, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, incontinent care, catheter care, dialysis services, and infection prevention for residents at Park Manor of Westchase.
Findings
The facility failed to provide timely and appropriate incontinent care to residents, resulting in risks of discomfort, infection, and dignity issues. Deficiencies were noted in catheter care, including improper handling of Foley bags and tubing, and incomplete dialysis communication documentation. These failures could lead to urinary tract infections, skin breakdown, and inadequate dialysis care.
Deficiencies (5)
Failure to provide timely incontinent care to Resident #80, resulting in saturated briefs and linens.
Failure to ensure Foley bag and tubing were not placed on the floor for Resident #87 and Resident #27.
Failure of CNA J to clean Resident #80 completely during incontinent care.
Failure to separate Resident #80's labia properly during incontinent care, risking UTI.
Failure to consistently document Resident #244's dialysis communication form.
Report Facts
Residents reviewed for ADLs: 4
Residents reviewed for incontinent care: 4
Residents reviewed for dialysis services: 3
Dates missing dialysis communication forms: 9
Dates missing post-dialysis assessment: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Certified Nursing Assistant | Named in findings related to delayed incontinent care and incomplete cleaning of Resident #80 |
| LVN O | Licensed Vocational Nurse | Named in findings related to Foley care for Resident #27 |
| ADON | Assistant Director of Nursing | Provided interviews regarding care standards and monitoring of aides and nurses |
| DON | Director of Nursing | Provided interviews regarding care deficiencies and expectations for staff |
| LVN A | Licensed Vocational Nurse | Provided interview regarding dialysis communication form responsibilities |
| LVN B | Licensed Vocational Nurse | Provided interview regarding dialysis communication form and post-dialysis care |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 22, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards in providing dialysis care and services to residents requiring such treatment.
Findings
The facility failed to consistently document dialysis communication forms for Resident #244 on multiple dates, which could place residents at risk for complications and inadequate care. Interviews with staff confirmed lapses in completing and filing these forms, and the facility lacked a dialysis policy.
Deficiencies (1)
Failure to consistently document Resident #244's dialysis communication forms on multiple dates.
Report Facts
Missing dialysis communication forms: 9
Missing post-dialysis assessment information: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON A | Assistant Director of Nursing | Interviewed regarding dialysis communication form completion and record checks. |
| LVN A | Licensed Vocational Nurse | Interviewed about documentation practices for dialysis communication forms. |
| DON | Director of Nursing | Interviewed about nursing staff responsibilities and facility dialysis policy. |
| LVN B | Licensed Vocational Nurse | Interviewed about dialysis communication form completion and related care practices. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 19, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents reviewed for treatment of pressure ulcers.
Complaint Details
The visit was complaint-related due to allegations of inadequate pressure ulcer care leading to infections, hospitalizations, and amputation. Immediate Jeopardy was identified on 09/15/2023 and removed on 09/18/2023, but the facility remained out of compliance with actual harm severity.
Findings
The facility failed to provide daily wound care according to physician orders for three residents, resulting in wound infections, hospitalizations, and amputation. Documentation of wound care was missing on multiple days, and wound care training for nurses was inadequate. An Immediate Jeopardy was identified but later removed, with the facility remaining out of compliance at a severity of actual harm.
Deficiencies (4)
Failure to provide daily wound care for three residents resulting in wound infections, hospitalization, and amputation.
Failure to follow physician orders and treat pressure wounds daily for multiple days.
Failure to document wound care provided on multiple days.
Failure to provide wound care training for nurses responsible for wound care.
Report Facts
Missed wound care documentation days for Resident #1: 20
Missed wound care documentation days for Resident #2: 25
Missed wound care documentation days for Resident #3: 18
Wound sizes for Resident #1: 10
Wound sizes for Resident #2: 8.2
Wound sizes for Resident #3: 2
Blood sugar range for Resident #1: 476
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse I | Documented progress note about Resident #1's hospitalization and condition change | |
| ADON | Assistant Director of Nursing | Interviewed regarding Resident #1's hospitalization and wound care documentation issues |
| Wound Care Doctor | Provided wound care notes and infection culture results for residents | |
| Nurse A | Interviewed about wound care responsibilities and facility practices | |
| Nurse B | Assigned nurse for Resident #3, interviewed about missed wound care documentation | |
| Nurse C | Interviewed about wound care training and practices | |
| CNA B | Certified Nursing Assistant | Interviewed about resident turning and dressing observations |
| Nurse D | Interviewed about wound care responsibilities and training | |
| Nurse L | Interviewed about wound care documentation and practice | |
| Nurse E | Interviewed about wound care documentation and responsibilities | |
| Nurse Practitioner | Interviewed about physician orders and wound care expectations |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation related to neglect and abuse involving Resident #1 who sustained a fall resulting in a left femur fracture and subsequent death.
Complaint Details
The complaint involved neglect and abuse allegations for Resident #1 who sustained multiple falls culminating in a serious injury and death, and Resident #19 who alleged inappropriate conduct by a staff member. The facility failed to provide adequate supervision, timely communication of X-ray results, and timely investigation and reporting of neglect allegations.
Findings
The facility failed to ensure adequate supervision to prevent Resident #1's fall, failed to timely notify the nurse practitioner of X-ray results, and failed to update the resident's care plan after multiple falls. An Immediate Jeopardy was identified but later removed. The facility also failed to thoroughly investigate and report allegations of neglect related to Resident #19 in a timely manner.
Deficiencies (4)
Failure to ensure adequate supervision to prevent Resident #1's fall resulting in serious injury and death
Failure to timely notify the nurse practitioner of X-ray results for Resident #1
Failure to update Resident #1's care plan and implement interventions after multiple falls
Failure to thoroughly investigate and report allegations of neglect related to Resident #19 within 5 working days
Report Facts
Fall risk assessment audit: 19
BIMS score: 3
BIMS score: 11
Fall risk assessment score: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Assessed Resident #1 after fall, ordered X-ray, faxed X-ray results to NP |
| LVN B | Licensed Vocational Nurse | Received X-ray results, failed to notify NP of impressions, worked with Resident #1 |
| DON | Director of Nursing | Interviewed regarding fall incident, supervision failures, and staff training |
| Administrator | Facility Administrator | Interviewed regarding fall incident, supervision failures, and reporting |
| Activity Assistant B | Activity Assistant | Transported residents including Resident #1, confirmed Resident #1 was left unattended |
| CNA B | Certified Nursing Assistant | Alleged by Resident #19 of inappropriate conduct, denied allegations |
| MDS Coordinator A | MDS Nurse | Responsible for MDS assessments, described care plan responsibilities |
| ADON | Assistant Director of Nursing | Interviewed regarding fall risk assessments and supervision |
| RN | Registered Nurse | Interviewed regarding fall incident and care plan deficiencies |
| Social Worker | Social Worker | Interviewed regarding Resident #19 room change and allegations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 24, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to develop and implement an accurate comprehensive person-centered care plan and to provide safe and appropriate respiratory care for Resident #1.
Complaint Details
The investigation was complaint-driven, focusing on Resident #1's care planning and respiratory care. The complaint was substantiated with findings of care plan inaccuracies and respiratory care deficiencies.
Findings
The facility failed to include Resident #1's use of oxygen and pacemaker in the care plan and failed to set the oxygen flow rate correctly per physician orders. Staff did not provide oxygen consistently, including during transport to dialysis, and there was confusion over oxygen orders. These failures posed risks of inadequate care and respiratory support.
Deficiencies (2)
Failed to develop and implement an accurate comprehensive person-centered care plan for Resident #1, omitting oxygen use and pacemaker.
Failed to provide safe and appropriate respiratory care by not setting oxygen flow rate at 2 liters as ordered and failing to provide oxygen during transport to dialysis.
Report Facts
Oxygen flow rate: 2
Oxygen flow rate: 3
Resident #1 last day at facility: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN #1 | Licensed Vocational Nurse | Acknowledged oxygen order but did not read physician orders and confirmed mistake in oxygen setting |
| LVN #2 | Licensed Vocational Nurse | Conducted rounds, checked oxygen levels, and explained oxygen settings |
| DON | Director of Nursing | Interviewed regarding care planning and oxygen order oversight |
| ADON | Assistant Director of Nursing | Interviewed regarding care planning responsibilities and assessment follow-up |
| Unit Manager | Unit Manager | Interviewed regarding care plan review responsibilities |
| Administrator | Administrator | Interviewed regarding care planning oversight and facility systems |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Park Manor of Westchase nursing home.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 12
Deficiencies: 2
Date: Oct 6, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the safety, cleanliness, and proper medication storage in the nursing home environment.
Findings
The facility failed to maintain a safe, clean, and homelike environment for one resident due to visible brown liquid splatter stains in the resident's room that were not cleaned promptly. Additionally, the facility failed to ensure that a nurse medication cart was secured when unattended, posing risks of medication loss, resident safety, and drug diversion.
Deficiencies (2)
Failure to provide a safe, clean, comfortable, and homelike environment for Resident #234, evidenced by brown liquid splatter stains on the wall and floor beside the resident's bed that were not cleaned.
Failure to ensure the Nurse Medication Cart 200 Hall was secured when unattended, with unlocked drawers containing medications and narcotics.
Report Facts
Census: 12
Residents observed for housekeeping services: 6
Residents affected: 1
Medication carts observed: 6
Medication cart unsecured: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN G | Licensed Vocational Nurse | Stated responsibility for locking medication carts and plan to prevent future occurrences |
| Housekeeper A | Housekeeper | Interviewed regarding cleaning of Resident #234's room and acknowledged need to clean stains |
| Housekeeping Manager | Housekeeping Manager | Acknowledged that the room should have been cleaned and stated infection control risks |
| Administrator | Administrator | Observed stains in Resident #234's room and stated expectation that medication carts be secured |
| DON | Director of Nursing | Accompanied observation of medication cart and stated risks of unlocked medication carts |
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