Inspection Reports for The Heights of North Houston
303 Hollow Tree Ln, Houston, TX 77090, United States, TX, 77090
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
129% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 4
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to evaluate the facility's pharmaceutical services and medication administration practices, specifically focusing on the accuracy and completeness of controlled drug records and medication administration records (MAR) for residents.
Findings
The facility failed to maintain an established system of records for receipt and disposition of controlled drugs, resulting in missing documentation of Morphine and ABH cream administration for one resident. These failures posed risks of inaccurate medication administration, overmedication, or drug diversion. Interviews with staff confirmed lapses in documentation, and the facility implemented in-services and audits to improve compliance.
Deficiencies (4)
Failed to have an established system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation.
Failed to document ABH cream on May 2025 MAR for resident #1.
Failed to document Morphine on April 2025 MAR for resident #1.
Failed to document Morphine on May 2025 MAR for resident #1.
Report Facts
Residents reviewed for pharmacy services: 5
BIMS score: 2
Dates/times of missing Morphine administration: 6
Dates/times of missing ABH cream administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Interviewed regarding medication administration and documentation lapses for resident #1 |
| LVN R | Licensed Vocational Nurse | Interviewed regarding missing entries on Controlled Drug Log and MAR for resident #1 |
| LVN A | Licensed Vocational Nurse | Interviewed regarding missing entries on MAR for resident #1 |
| LVN S | Licensed Vocational Nurse | Attempted interview regarding missing entries on Controlled Drug Log for resident #1 but unsuccessful |
| DON | Director of Nursing | Interviewed about medication documentation issues and corrective actions including audits and in-services |
Inspection Report
Routine
Deficiencies: 3
Date: May 8, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment, specifically reviewing environmental concerns in resident bathrooms.
Findings
The facility failed to maintain cleanliness and proper condition in 3 of 4 resident bathrooms reviewed, including yellow stains on toilet seats and bowls, and peeling black tread tape on bathroom floors. These conditions posed a risk of diminished quality of life due to an unpleasant, unsanitary, and unsafe environment.
Deficiencies (3)
Toilet in one resident bathroom was not kept clean and had a large yellow stain in the bowl.
Toilet seats in multiple resident bathrooms had yellow stains.
Bathroom floors in one resident bathroom were covered in peeling black tread tape that was no longer intact.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Regional Supervisor | Provided information about housekeeping cleaning practices and challenges with stains and floor tape. | |
| Maintenance Director | Discussed the condition and history of bathroom tread tape and toilet seats, and cleaning procedures involving bleach. |
Inspection Report
Routine
Deficiencies: 4
Date: May 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding medication labeling and storage, food service safety, infection prevention and control, and pest control in the facility.
Findings
The facility was found deficient in ensuring proper labeling and secure storage of medications, maintaining kitchen sanitation including condensation on vents and pest control, and establishing an effective infection prevention and control program, particularly regarding Legionella monitoring.
Deficiencies (4)
Failed to ensure drugs and biologicals were labeled according to professional principles and stored securely; medication not prescribed to Resident #2 was left unattended on bedside tray and nursing cart.
Failed to store, prepare, distribute and serve food in accordance with professional standards; kitchen vents above steam table had dripping condensation.
Failed to establish and maintain an infection prevention and control program; no documentation of regular testing and monitoring of environmental control limits for water management plan.
Failed to maintain an effective pest control program; a live roach was observed in the dishwashing area.
Report Facts
Medication carts reviewed: 6
Resident rooms reviewed: 15
Condensation vents observed: 4
Pest control visit date: May 2, 2025
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Interviewed regarding medication left on Resident #2 bedside tray |
| DON | Director of Nursing | Interviewed regarding medication labeling, storage, and infection control program |
| CNA L | Certified Nursing Assistant | Interviewed regarding bathing Resident #2 and use of skin products |
| LVN A | Licensed Vocational Nurse | Interviewed regarding unattended nursing cart and medication storage |
| Dietary Manager | Interviewed regarding kitchen sanitation and pest control | |
| Dietary Aide A | Interviewed regarding observation of roach in kitchen | |
| Maintenance Supervisor | Interviewed regarding kitchen vent maintenance and condensation | |
| Administrator | Interviewed regarding kitchen sanitation, infection control, and Legionella program | |
| Infection Preventionist | Interviewed regarding infection prevention and control program |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 1, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to coordinate PASRR assessments and screenings for Resident #13, inadequate supervision leading to elopement of Resident #100, and failure to ensure medication carts were free of expired medications.
Complaint Details
The complaint investigation included issues with failure to coordinate PASRR assessments for Resident #13, inadequate supervision and training leading to Resident #100 eloping and being discharged AMA without proper documentation, and expired medications found in medication carts. The immediate jeopardy related to Resident #100's elopement was identified as past non-compliance and was corrected by in-servicing and training prior to state entrance.
Findings
The facility failed to coordinate PASRR assessments for Resident #13, potentially risking necessary care. The facility also failed to provide adequate supervision and training, resulting in Resident #100 eloping and being discharged without proper documentation, posing immediate jeopardy. Additionally, expired medications were found in medication carts, risking resident health.
Deficiencies (3)
Failure to coordinate PASRR assessments and screenings for Resident #13, risking necessary therapeutic services.
Failure to ensure resident environment was free from accident hazards and provide adequate supervision, resulting in Resident #100 eloping and being discharged without proper documentation.
Failure to ensure medication carts were free of expired medications including Lemon Glycerin swab sticks and lubricating jelly.
Report Facts
Expired Lemon Glycerin swab sticks: 16
Expired Lubricating jelly sachets: 4
BIMS score: 1
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator A | Interviewed regarding PASRR submissions and therapy documentation for Resident #13 | |
| Director of Rehab | Interviewed about therapy requests and PASRR submissions for Resident #13 | |
| Senior Director of Clinical Reimbursement | Interviewed about Resident #13's therapy refusals and treatments | |
| LVN C | Last staff to see Resident #100 before elopement | |
| RN B | Marked Resident #100 as discharged without verifying physician orders | |
| DON | Director of Nursing | Interviewed extensively about Resident #100 elopement and facility corrective actions |
| RN A | Interviewed about medication cart checks and elopement procedures | |
| LVN B | Interviewed about expired medication found in medication cart |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 1, 2024
Visit Reason
The inspection was conducted based on complaints and observations regarding failure to coordinate PASRR assessments, inadequate supervision leading to resident elopement, improper incontinent care, medication errors, and infection control issues.
Complaint Details
The complaint investigation included issues of failure to coordinate PASRR assessments, inadequate supervision resulting in elopement, improper incontinent care, medication errors, and infection control deficiencies. The elopement was identified as past noncompliance with immediate jeopardy from 5/22/23 to 5/24/23, which the facility corrected prior to state entrance by providing staff training.
Findings
The facility failed to coordinate PASRR assessments for Resident #13, failed to provide adequate supervision resulting in elopement of Resident #100, failed to provide appropriate incontinent care for Resident #30, had medication errors involving Residents #36 and #75, and failed to maintain an effective infection control program.
Deficiencies (7)
Failed to coordinate PASRR assessments and screenings for Resident #13, risking lack of necessary therapeutic services.
Failed to provide adequate supervision and training leading to elopement of Resident #100, placing residents at risk of harm.
Failed to provide appropriate incontinent care for Resident #30, including improper cleaning technique and hand hygiene.
Failed to provide appropriate care to prevent urinary tract infections for Residents #30 and #66, including failure to secure Foley catheter tubing.
Failed to ensure medication carts did not contain expired medications for 100 and 300 halls.
Medication error rate was 8%, including wrong dosage of Turmeric capsule to Resident #75 and wrong dosage of Potassium Chloride to Resident #36.
Failed to maintain an infection control program, including failure of CNA A to perform proper hand hygiene and glove changes during incontinent care for Resident #30.
Report Facts
Medication error rate: 8
Medication errors: 2
BIMS score: 1
BIMS score: 2
BIMS score: 7
BIMS score: 4
BIMS score: 9
Expired medication count: 16
Expired medication count: 4
Medication dosage error: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA B | Medication Aide | Prepared and administered wrong dosage of Turmeric capsule to Resident #75 |
| LVN A | Licensed Vocational Nurse | Poured wrong dosage of Potassium Chloride to Resident #36 |
| CNA A | Certified Nursing Assistant | Failed to perform proper incontinent care and hand hygiene for Resident #30 |
| LVN T | Licensed Vocational Nurse | Failed to secure Foley catheter tubing for Resident #66 |
| Director of Nursing | DON | Interviewed multiple times regarding findings and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 12, 2023
Visit Reason
The inspection was conducted due to complaints and incidents involving failure to timely report suspected abuse, neglect, or injury, and failure to ensure adequate supervision and safe use of equipment leading to resident injuries and death.
Complaint Details
The complaint investigation involved allegations of neglect and failure to report a resident fall with injury that resulted in death. The facility also failed to provide adequate supervision and safe equipment use, leading to falls and injuries for two residents. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to timely report an injury and fall of a resident resulting in death, failed to ensure adequate supervision and assistance during care leading to falls and injuries for two residents, and failed to ensure safe use and inspection of Hoyer lift equipment causing injury. Immediate Jeopardy was identified but later removed after corrective actions.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or injury to proper authorities for 1 of 2 residents reviewed.
Failure to ensure resident environment was free from accident hazards and provide adequate supervision to prevent accidents, resulting in injuries from falls and equipment failure for 2 residents.
Report Facts
Residents reviewed for allegation of neglect: 2
Residents affected by deficiencies: 2
Time of fall incident: 23
Immediate Jeopardy identified: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Assessed resident after fall and called 911 |
| CNA B | Certified Nursing Assistant | Provided incontinent care and assisted resident who fell |
| DON | Director of Nursing | Notified of fall incident, involved in training and corrective actions |
| Administrator | Facility administrator interviewed regarding failure to report incident | |
| CNA A | Certified Nursing Assistant | Involved in Hoyer lift transfer when sling broke causing resident fall |
| CNA M | Certified Nursing Assistant | Involved in Hoyer lift transfer when sling broke causing resident fall |
| Laundry Staff A | Laundry Staff | Responsible for laundering Hoyer lift slings |
| Regional Director of Clinical Operation | Provided information on staff training and corrective actions | |
| CNA K | Certified Nursing Assistant | Interviewed about training on Hoyer lift |
| CNA J | Certified Nursing Assistant | Observed transferring resident with Hoyer lift |
| CNA L | Certified Nursing Assistant | Observed transferring resident with Hoyer lift |
| CNA P | Agency Staff | Interviewed about knowledge of two person assist requirements |
| RN A | Registered Nurse | Received recent training on Hoyer lift transfer |
| CNA C | Certified Nursing Assistant | Received training on Hoyer lift transfer and inspection |
| CNA D | Certified Nursing Assistant | Received training on Hoyer lift transfer and inspection |
| CNA E | Agency Staff | Received training on Hoyer lift use and checking resident assistance needs |
| CNA F | Certified Nursing Assistant | Observed performing Hoyer lift transfer with inspection |
| CNA G | Certified Nursing Assistant | Observed performing Hoyer lift transfer with inspection |
Inspection Report
Routine
Deficiencies: 9
Date: Dec 30, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, infection control, medication administration, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a sanitary environment, inadequate personal care and incontinent care for residents, medication errors including missed and expired medications, improper infection control practices, unsafe food storage, and improper waste disposal. These deficiencies placed residents at risk for infection, skin breakdown, diminished quality of life, and potential harm.
Deficiencies (9)
Failure to maintain a sanitary, orderly, and comfortable environment, including sewage odor in Resident #135's restroom.
Failure to provide routine showers and timely incontinent care to Resident #135.
Failure to provide care and assistance for activities of daily living for Resident #135.
Failure to provide appropriate treatment and care according to orders and resident preferences for Residents #40 and #75, resulting in Moisture Associated Skin Damage (MASD).
Failure to provide appropriate care to prevent urinary tract infections and ensure proper catheter and incontinent care for Residents #30 and #135.
Medication errors including missed administration of Furosemide to Resident #52, administration of expired insulin to Resident #65, and incorrect dosing of eye drops to Resident #66.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including presence of dented cans, food on the floor, and expired or moldy fruit in the kitchen.
Failure to properly dispose of garbage and refuse, including unsecured dumpster lids and doors.
Failure to provide and implement an effective infection prevention and control program, including improper glove use, hand hygiene, PPE use, and handling of contaminated linens and gowns.
Report Facts
Medication error rate: 10
Number of dented cans: 3
Number of plastic containers of expired fruit: 4
Number of dented cans: 3
Number of plastic containers of moldy fruit: 4
Medication errors: 3
Furosemide dose: 20
Insulin aspart dose: 8
Cyclosporine eye drops: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Registered Nurse | Did not administer Humulin N insulin to Resident #16; missed Furosemide dose for Resident #52 |
| LVN P | Licensed Vocational Nurse | Administered expired insulin aspart to Resident #65 |
| MA A | Medication Aide | Administered four drops of Cyclosporine eye drops per eye instead of one drop for Resident #66 |
| CNA C | Certified Nursing Assistant | Failed to change gloves and perform hand hygiene during incontinent care for Resident #10 |
| CNA AA | Certified Nursing Assistant | Failed to change gloves and perform hand hygiene during incontinent care for Resident #29 and bed linen change for Resident #135 |
| CNA BB | Certified Nursing Assistant | Failed to change gloves during wound care for Resident #26; improperly used gloves from uniform pocket during wound care for Resident #75; improperly handled linens for Resident #135 |
| CNA T | Certified Nursing Assistant | Placed Foley bag on bed at bladder level during wound care for Resident #40; used gloves from uniform pocket during wound care for Resident #75 |
| WFM YY | Failed to properly clean Resident #135 during incontinent care; improper hand hygiene | |
| Housekeeping A | Improper use of gloves during trash pickup from resident's room | |
| ADON | Assistant Director of Nursing | Improper handling of disposable gown outside resident room |
| Dietary Supervisor | Acknowledged food safety violations and improper food storage | |
| Administrator | Acknowledged infection control and housekeeping deficiencies | |
| DON | Director of Nursing | Provided multiple interviews regarding infection control, medication errors, and care deficiencies |
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