Inspection visit
Inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide a safe, functional, sanitary,
comfortable, and homelike environment for one of twelve residents (Resident #2) reviewed for a safe, clean,
and homelike environment.
-The facility failed to ensure Resident #2 had a working light in her room above her sink.
-The facility failed to ensure the residents who smoked cigarettes had a safe, comfortable seating area
available as the bench in the smoking area was broken.
These failures could place the residents at risk of injury from the visible nails on the bench in the smoking
area and could place the residents at risk of decreased quality of like due to the lack of a well-maintained
environment.
Findings include:
Record review of Resident #2's admission record dated 12/12/023 revealed a [AGE] year-old woman
admitted on [DATE]. The admission record documented her diagnoses included dementia (group of
symptoms that affects memory, thinking and interferes with daily life), unspecified psychosis (diagnosis
assigned to individuals who are experiencing symptoms of schizophrenia or other psychotic symptoms, but
do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder),
repeated falls, schizoaffective disorder (mental disorder in which a person experiences a combination of
symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder having
episodes of psychological depression), HIV (virus that attacks cells that help the body fight infection,
making a person more vulnerable to other infections and diseases), anxiety disorder (group of mental
illnesses that cause constant fear and worry), insomnia (trouble falling and/or staying asleep), and
convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement).
Record review of Resident #2's quarterly MDS dated [DATE] with an ARD of 11/13/2023 revealed a BIMS
score of 15 indicating no cognitive decline. The MDS documented she required a walker for mobility. Per the
MDS, Resident #2 minimal assistance with her ADL's including eating, hygiene, toileting, bathing, dressing,
and/or personal hygiene. The MDS revealed she had adequate vision abilities with the use of corrective
lenses. The MDS documented Resident #2 received PT services.
Record review of Resident #2's care plan dated 12/19/2023 revealed she had a focus on her ADL needs
with interventions including minimal assistance with locomotion, bed mobility, eating, transfers,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 18
Event ID:
676470
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
and incontinence care. The care plan documented a focus on her behavioral concerns. There was no
documented focus on her vision needs.
Interview on 12/12/2023 at 9:23 AM with Resident #2, she said she had lived at the facility for nine years.
Resident #2 said the light above her sink was not working.
Residents Affected - Some
Observation on 12/12/2023 at 9:23 AM of Resident #2's call light and bedroom, the light over the sink in
Resident #2's room would not turn on whether the switch was in the on or off position.
Interview on 12/12/2023 at 11:25 AM with Resident #2, she said she had spoken to staff about the broken
light in her room but no one from the facility had repaired it yet. Resident #2 said she could not recall who
she had spoken to or how long the light had been broken.
Observation on 12/13/2023 at 8:29 AM revealed the bench in the smoking area was in disrepair. The back
of the bench had become partially dislodged from the base and nails were visible. A nurse and a resident
were both sitting on the bench.
Interview on 12/13/2023 at 12:19 PM with the Acting DON, he said he had never been informed of the
malfunctioning light in Resident #2's room. The Acting DON said if he had been informed, he would have
ensured it was repaired. The Acting DON said his expectations were that as soon as staff were informed
that a resident's room was not homelike, the staff or an outside technician should repair the concern.
Interview on 12/14/2023 at 3:47 PM with the Admin, she said the facility had no specific policy related to
facility maintenance and/or repair. The Admin said the facility utilized an electronic repair request system in
which repairs were requested and completed.
Interview on 12/14/2023 at 4:28 PM with the Admin, she said no one had ever informed her that the bench
in the smoking area was broken. The Admin said no one had ever informed her the light in Resident #2's
room was not working. The Admin said the facility staff should have been aware of the light and the bench.
The Admin said issues such as the bench and Resident #2's light would have been entered into the
electronic repair system to ensure repair. The Admin said she had removed the bench completely and had
replaced it with two chairs.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 2 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure residents who needed respiratory care
were provided such care, consistent with professional standards of practice for 1 (Resident #290,) of 3
resident reviewed for respiratory care.
Residents Affected - Few
-The facility administered oxygen to Resident #290 without a physician order.
These failures placed residents who received oxygen therapy at risk of respiratory complications.
Findings include:
Record review of Resident #290's admission face sheet dated 10/19/23 revealed an [AGE] year-old female
who was initially admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included diabetes
mellitus (metabolic disease involving Hight blood glucose levels), hypertension (blood is pumping with more
force than normal through arteries), dementia (impaired ability to remember, think, or make decisions that
interferes with doing everyday activity) and chronic obstructive pulmonary disease (lung disease causing
restricted airflow and breathing problem).
Record review of Resident #290's 5-day MDS assessment, dated 12/08/23, revealed the BIMS score was
04, which indicated severely impaired cognition. Further review of the MDS revealed she required oxygen
therapy.
Record review of Resident #290's physician's order for December 2023 revealed there was no oxygen
order until 12/12/23.
Record review of Resident #290's hospital discharge order dated 12/04/23 read oxygen at 2L .
During an observation and interview on 12/12/23 at 10:05 a.m., Resident #290 was on oxygen, and the
concentrator was set to 2.5 L. The NC (nasal canula) was on the floor under the bed. Resident #290 said
she could not remember how many liters of oxygen she should be on. Resident #290 said she was having
some difficulty breathing at this time.
During an observation on 12/12/23 at 10:07 a.m., LVN J said the O2 (oxygen) tubing was on the floor under
the bed.
During an interview on 12/12/23 at 10:15 a.m., LVN J said the oxygen should be on 2L continuously, and
she moved the knob on the concentrator down to 2L. Then, LVN J said she would check Resident #290's
physician orders and clarify if the oxygen setting should be on 2L.
During an Interview on 12/12/23 at 12:09 p.m., LVN J said Resident #290 came from the hospital
on12/04/23 with oxygen, and she was not the nurse who admitted Resident #290 back to the facility. LVN J
said she worked with Resident #290 last week, and Resident #290 was on continuous oxygen. LVN J said
Resident #290 should have an order for oxygen before administering oxygen. LVN J said she checked
Resident #290's oxygen saturation, which fluctuated between 93% and 94 %. LVN J said she did not know
how they dropped the ball and did not get an order for the oxygen. LVN J said the DON verified Resident
#290 orders when she was admitted to the facility, and she did not realize she did not get an order for the
oxygen. LVN J said Resident #290 could go into respiratory distress if Resident #290
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 3 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
was not getting enough oxygen or more than required because she was diagnosed with COPD.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 12/13/23 at 3:07 p.m., LVN MDS said she independently prepared the MDS and
care plan. LVN MDS said she asked the interim DON to review the care plan and make corrections. LVN
MDS said Resident #290 was admitted to the facility on [DATE] and she had oxygen on when she was
admitted . After a couple of hours, the facility that Resident #290 came from, called and said Resident #290
had a critical lab and she was sent to the hospital. LVN MDS said Resident #290 was readmitted on [DATE]
with oxygen from the hospital. LVN MDS said the resident had oxygen since she came to the facility and the
interim DON verified her medications. LVN MDS said the interim DON should have clarified the oxygen
order because it was on her hospital discharged orders. LVN MDS said she added the oxygen to Resident
#290's MDS but forgot to care plan the oxygen use. LVN MDS said the interim DON and LVN J admitted
Resident #290 and failed to get an oxygen order from the physician. LVN MDS said Resident #290 could
have retained carbon dioxide, because she had COPD, which could have caused harm or she could have
passed out.
Residents Affected - Few
During an interview on 12/14/23 at 8:40 a.m., the Interim DON said Resident #290 should not be on oxygen
without a physician's order. The interim DON said all the residents on oxygen should have an order from the
physician for oxygen before oxygen is administered. The interim DON said the nurse who admitted
Resident # 290 should have called Resident #290's physician and verified discharged orders upon
admission. The interim DON stated the DON should have verified Resident #290's discharged orders,
contacted her physician for any discrepancies, and made corrections the next day. The interim DON said
these actions would have prevented Resident #290 from being administered oxygen for at least a week
without an order. The interim DON said administering oxygen to Resident #290 could have a negative
outcome depending on the oxygen setting. The Interim DON said it could have interfered with CO2 if there
was too much oxygen going in since Resident #290 had a diagnosis of COPD.
Record review of the facility policy dated 2001 MED - PASS, Inc. (Revised October 2010) read in part, . the
purpose of this procedure is to provide guideline for safe oxygen administration . preparation: #1. Verify that
there is a physician's order for this procedure . review the physician's order . for oxygen administration .
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 4 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at
least eight consecutive hours a day, seven days a week in the facility for 36 of 92 days (09/11/2023,
09/12/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/17/2023, 09/18/2023, 09/19/2023, 09/20/2023,
09/21/2023, 09/22/2023, 09/23/2023, 09/25/2023, 09/26/2023, 09/27/2023, 09/28/2023, 09/29/2023,
09/30/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023,
10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 11/02/2023, 12/05/2023, 12/06/2023,
12/07/2023, 12/08/2023, and 12/11/2023) reviewed during a look back period from 09/11/2023 to
12/11/2023.
-The facility failed to have RN coverage in the facility for eight consecutive hours on 09/11/2023,
09/12/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/17/2023, 09/18/2023, 09/19/2023, 09/20/2023,
09/21/2023, 09/22/2023, 09/23/2023, 09/25/2023, 09/26/2023, 09/27/2023, 09/28/2023, 09/29/2023,
09/30/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023,
10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 11/02/2023, 12/05/2023, 12/06/2023,
12/07/2023, 12/08/2023, and 12/11/2023.
This failure could affect the residents by placing them at risk for not having their nursing and medical needs
met and receiving improper care.
Findings include:
Review of the facility's Timecard Detail sheets dated 12/13/2023 reflected there was not eight consecutive
hours of coverage by an RN on the following days/dates:
Monday 09/11/2023
Tuesday 09/12/2023
Wednesday 09/13/2023
Thursday 09/14/2023
Friday 09/15/2023
Sunday 09/17/2023
Monday 09/18/2023
Tuesday 09/19/2023
Wednesday 09/20/2023
Thursday 09/21/2023
Friday 09/22/2023
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 5 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Saturday 09/23/2023
Level of Harm - Minimal harm
or potential for actual harm
Monday 09/25/2023
Tuesday 09/26/2023
Residents Affected - Many
Wednesday 09/27/2023
Thursday 09/28/2023
Friday 09/29/2023
Saturday 09/30/2023
Monday 10/02/2023
Tuesday 10/03/2023
Wednesday 10/04/2023
Thursday 10/05/2023
Friday 10/06/2023
Saturday 10/07/2023
Sunday 10/08/2023
Monday 10/09/2023
Tuesday 10/10/2023
Wednesday 10/11/2023
Thursday 10/12/2023
Friday 10/13/2023
Thursday 11/02/2023
Tuesday 12/05/2023
Wednesday 12/06/2023
Thursday 12/07/2023
Friday 12/08/2023
Monday 12/11/2023
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 6 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Interview with the Admin on 12/14/23 at 10:00 AM revealed she began her position at the facility on
09/26/2023. She said she was aware the facility did not have RN coverage for several days after starting
her position. The Admin said she understood the facility is required to have an RN in the facility every day
for eight consecutive hours a day and seven days a week. She said the RN coverage currently is being
covered by the Regional Director of Clinical Services and he will be at the facility every day until the facility
has a DON on board. She said she has one potential candidate for the DON position going through a third
interview next week. She said she has run an ad for a PRN RN position as a backup, so she does not have
to deal with the stress of RN coverage in the future. The Admin said not having RN coverage as required
affects residents because an RN has more knowledge, and they are able to double check and sign off on
things an RN can only sign off on. She also said if she has an RN onsite, she does not have to reach out to
someone else to get things done.
The Admin said she does not have a policy for RN coverage.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 7 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were
stored in accordance with currently accepted professional principles for 1 of 1 medication aide cart and 1 of
1 medication room refrigerator reviewed for medications.
-1 of 1 medication aide cart had two discontinued medications.
-1 of 1 medication rooms had a water bottle (Ozarka) 700 ml sport cover in the freezer section of the
refrigerator.
These failures could affect residents, placing them at risk for altered effectiveness of the medication and
worsening of the resident's symptoms, requiring medical intervention.
The findings include:
During an observation on 12/13/23 at 2:35 p.m., revealed the medication aide's cart had two discontinued
medications: Clopidogrel 75 mg and Metoprolol [NAME] 25mg were left in the cart.
During an interview on 12/13/23 at 2:35 p.m., MA T said the doctor discontinued medications because the
resident brought them from home, and it was replaced with the medicines provided by the facility. MA T said
the staff should have taken the discontinued medication from the cart and placed it in the box in the
medication room.
During an observation of the medication room on 12/13/23 at 3:00 p.m., revealed the refrigerator in the
medication room had a water bottle (Ozarka) 700 ml sports cover in the freezer section of the fridge.
During an interview on 12/13/23 at 3:00 p.m., MA T said the refrigerator should have only the residents and
facility medications, no personal food or drinks from the staff to prevent cross-contamination.
During an interview on 12/13/23 at 3:18 p.m., LVN R said the refrigerator in the medication room was for
medication only, not for any staff personal items, to prevent cross-contamination.
During an interview on 12/13/23 at 3:20 p.m., LVN J said the water bottle should not be in the refrigerator
because it was used for medications only, and staff personal items are not stored in it because of infection
control.
During an interview on 12/13/23 at 3:55 p.m., the Interim DON said the nurses should remove the
medication the resident came with once the medication from the pharmacy comes in.
During an interview on 12/13/ at 3:59 p.m., the Interim DON said staff personal items (water and food)
should not be kept in the medication refrigerator in the medication room because of cross-contamination.
During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 8 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
skills check off for the nurses and medication aides.
Level of Harm - Minimal harm
or potential for actual harm
Record review of the facility policy on medication storage not dated policy read in part, . facility staff should
place open on date to medications label for medications with limited expiration date upon opening . food is
not stored with refrigerated medications .
Residents Affected - Few
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 9 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, and record review, the facility failed to act upon the recommendations of the pharmacist report
of irregularities for 1 of 6 residents (Resident #2), reviewed for the Medication Regimen Review (MRR).
-The facility failed to review and act on the pharmacist's Resident #2's to utilize the correct consent form.
This failure could place residents at risk from maintaining their highest practicable level of physical, mental,
and psychosocial well-being, and could place them at risk for not providing informed consent to a
psychotropic medication.
The findings include:
Record review of Resident #2's admission record dated 12/12/023 revealed a [AGE] year-old woman
admitted on [DATE]. The admission record documented her diagnoses included dementia (group of
symptoms that affects memory, thinking and interferes with daily life), unspecified psychosis (diagnosis
assigned to individuals who are experiencing symptoms of schizophrenia or other psychotic symptoms, but
do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder),
repeated falls, schizoaffective disorder (mental disorder in which a person experiences a combination of
symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder having
episodes of psychological depression), HIV (virus that attacks cells that help the body fight infection,
making a person more vulnerable to other infections and diseases), anxiety disorder (group of mental
illnesses that cause constant fear and worry), insomnia (trouble falling and/or staying asleep), and
convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement).
Record review of Resident #2's November MAR dated 12/12/2023 revealed a prescription for Aripiprazole
(an antipsychotic medication used for treatment of agitation that occurs with certain mental and/or mood
disorders) 20mg tablet, one tablet, once daily for schizoaffective disorder. The MAR documented it was
given daily at 9:00 AM on 11/1/2023 through 11/30/2023 except 11/4/2023. Per the MAR, the prescription
began on 8/29/2023.
Record review of Resident #2's December MAR dated 12/12/2023 revealed a prescription for Aripiprazole
20mg tablet, one tablet, once daily for schizoaffective disorder. The MAR documented it was given daily at
9:00 AM on 12/1/2023 through 12/12/20233. Per the MAR, the prescription began on 8/29/2023.
Record review of Resident #2's quarterly MDS dated [DATE] with an ARD of 11/13/2023 revealed a BIMS
score of 15 indicating no cognitive decline. The MDS documented she required a walker for mobility. Per the
MDS, Resident #2 minimal assistance with her ADL's including eating, hygiene, toileting, bathing, dressing,
and/or personal hygiene. The MDS revealed Resident #2 was prescribed an antipsychotic.
Record review of Resident #2's care plan dated 12/19/2023 revealed she had a focus on her ADL needs
with interventions including minimal assistance with locomotion, bed mobility, eating, transfers, and
incontinence care. The care plan documented a focus on her behavioral concerns. The care plan
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 10 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
included a focus on Resident #2's psychotropic medication use with interventions including monitoring for
signs or symptoms of side effects.
Record review of Resident #2's September 2023 MRR dated between 9/5/2023 and 9/7/2023 revealed the
pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer
appropriate to use the conventional informed consent form for antipsychotics.
Record review of Resident #2's October 2023 MRR dated between 10/1/2023 and 10/3/2023 revealed the
pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer
appropriate to use the conventional informed consent form for antipsychotics.
Record review of Resident #2's November 2023 MRR dated between 11/1/2023 and 11/3/2023 revealed
the pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer
appropriate to use the conventional informed consent form for antipsychotics.
Interview on 12/12/2023 at 9:23 AM with Resident #2, she said she had lived at the facility for nine years.
Resident #2 said she had no concerns with her medical care at the facility.
Interview on 12/12/2023 at 11:25 AM with Resident #2, she said she was aware of the medications she
took, and she had no concerns with those medications.
Interview on 12/13/2023 at 12:19 PM with the Acting DON, he said he had been Acting DON for five total
days. The Acting DON said he expected the MRR to be reviewed by the DON monthly after the pharmacist
provides the recommendations. The DON said a resident's updated medication consent forms should be
obtained by the DON. The DON said Resident #2's Aripiprazole consent should have been updated. The
DON said the consent form 3713 detailed the previous attempts and approaches to the underlying mental
illness, and without the correct form that would not be available when consent was granted.
Interview on 12/14/2023 at 3:47 PM with the Acting DON, he said the facility did not have a specific policy
related to MRR's or the DON's responsibility to them. The Acting DON said the facility utilized the
consultant pharmacy's policy related to MRR.
Telephone interview on 12/14/2023 at 12:57 PM the consultant pharmacist for the facility, she said the
facility does not currently have a DON. The Pharmacist said the facility had multiple consent for
psychotropic medication forms completed but they may not be uploaded. The Pharmacist said Resident
#2's correct consent form could be at the facility and not uploaded to the EMR. The Pharmacist said if the
facility could not produce the consent it would be a concern because certain medications require
appropriate consents to ensure the resident or their representative were able to give informed consent to
the medication.
Interview on 12/14/2023 at 4:28 PM with the Admin, she said she expected that the MRR was reviewed,
and the resident's physician was contacted to determine if the recommendations would be put in place. The
Admin said she expected the facility's nurses to follow-up and a obtain the correct consent for psychotropic
medications.
Record review of the undated consultant pharmacy's policy related to MRR revealed the pharmacist would
conduct an MRR for each resident at the facility monthly. The policy documented the purpose of the MRR
was to ensure the resident's were receiving the correct medication therapy. The policy read in part .All
findings and recommendations made during the MRR are reported to the director of nursing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 11 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 12 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure that the medication error rate was not
five percent or greater. The facility had a medication error rate of 7 % based on 2 errors out of 27
opportunities, which involved 1 of 11 residents (Resident #31) reviewed for medication errors.
Residents Affected - Few
- MA B was going to administer Metoprolol and Lisinopril (used to treat high blood pressure) and not follow
the blood pressure parameters according to the physician's orders for Resident #31.
This failure could place residents at risk for increased negative side effects and a decline in health.
Findings include:
Record review of Resident #31's Face Sheet dated 12/14/23 revealed, a [AGE] year-old female was
admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hypertension
(condition in which the blood vessels have persistently raised pressure), major depressive disorder (medial
illness that negatively affect how you feel, the way you think and how you act), and chronic obstructive
pulmonary disease ( group of disease that cause airflow blockage and breathing related problem).
Record review of Resident #31's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a
BIMS score of 10, which indicated the resident had moderately impaired cognition .
Record review of Resident #31's Care Plan initialed 10/13/21 revealed, resident had cardiac disease
related to CAD and HTN. Interventions: administer medication per physician orders.
Record review of Resident #31's order summary report for December 2023 revealed a start date for
Lisinopril 20 mg 1 tab po qd was started on 09/02/23, and the parameter read hold if SBP below 110.
Metoprolol Tartrate 50 mg 1 tab po qd hold for SBP less than 110, DBP less 60, and HR less 60.
Record review of Resident #31's MAR for December 2023 did not reveal any area to document the vital
signs.
During medication pass observation on 12/13/23 at 8:35 a.m., MA B was about to administer Lisinopril 20
mg and Metoprolol Tartrate 50 mg to Resident #31 without checking the residents blood pressure. The state
surveyor stopped the medication aide before administration.
During an interview on 12/13/23 at 8:38 a.m., M A B said she did not check Resident #31's blood pressure
because when she started working in the facility three months ago, she told the nurse who was on duty,
there was no area in MAR for documenting Resident #31's blood pressure and heart rate. MA B said the
nurse told her not to take Resident #31's blood pressure because Resident #31 was on blood pressure
medication for maintenance. MA B said the nurse no longer works for the facility.
During an interview on 12/13/23 at 8:41 a.m., the Interim DON said MA B should check Resident #31's
blood pressure before she administered blood pressure medication and documented it on the MAR. The
interim DON said if the blood pressure medication had a perimeter, there should be an area in the MAR for
documentation.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 13 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an observation on 12/13/23 at 8:49 a.m., MA B checked Resident #31's blood pressure on her right
wrist, and Resident #31's blood pressure was 102/50with a pulse of 87.
During an observation on 12/13/23 at 8:51 a.m., MA B rechecked Resident #31's blood pressure with an
electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure
was 144/93, and her pulse was 69.
During an observation on 12/13/23 at 8:55 a.m., LVN J checked Resident#31's blood pressure with an
electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure
was 97/71, and pulse was 63.
During an observation on 12/13/23 at 9:00 a.m., LVN J checked Resident #31's blood pressure with an
electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure
was 109/55 and pulse was 63.
During an interview on 12/13/23 at 9:02 a.m., LVN J said Resident #31's blood pressure medication would
be held because the blood pressure was below the parameter. LVN J said if MA B had given the blood
pressure medications to Resident#31, it would have caused Resident #3's blood pressure to drop more,
which could have made the resident dizzy or even fall. LVN J said she was not aware MA B was not
checking Resident #31's blood pressure before she gave blood pressure medication, and she did not tell
MA B not to check Resident #31's vitals. LVN J said she monitored MA B during medication administration
when she made random rounds, and the DON monitored the nurses when she made random rounds.
During an interview on 12/13/23 at 9:08 a.m., MA B said she would have given the medication without
checking Resident #31's blood pressure if the state surveyor had not intervened. MA B said Resident #31's
blood pressure could have dropped very low if she had given the blood pressure medications because it
was already below the parameter. MA B said Resident #31 could have had a negative outcome. MA B said
the floor nurse does monitor the medication aides during medication administration. She said she had a
skills check-off, and it included checking the resident's blood pressure before administering blood pressure
medication.
During an interview on 12/14/23 at 9:04 a.m., the Interim DON said Resident #31's blood pressure was low,
and if MA B administered BP medications to Resident #31, it could drop the BP even lower. The interim
DON said the negative outcome for Resident #31 could be dizziness and weakness. The interim DON said
if Resident #31's blood pressure medication had a parameter, then MA B should have checked blood
pressure before administering medication.
During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills
check off for the nurses and medication aides.
Record review of the undated facility policy on medication administration read in part . facility staff should
observe the six medication rights . right documentation for each resident . a triple check of these 5 rights is
recommended . if there is any other reason to question . or directions, the physician's orders are checked .
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 14 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure residents were free from any
significant medication errors for 1 of 11 residents (Residents #31) reviewed for significant medication
errors.
Residents Affected - Few
- MA B failed to administer medications as ordered by the physician to Resident # 31.
These failures could place residents at risk of not receiving the desired therapeutic effect of their
medications and negative outcomes.
Findings include:
Record review of Resident #31's Face Sheet dated 12/14/23 revealed, a [AGE] year-old female was
admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hypertension
(condition in which the blood vessels have persistently raised pressure), major depressive disorder (medial
illness that negatively affect how you feel, the way you think and how you act), and chronic obstructive
pulmonary disease (group of disease that cause airflow blockage and breathing related problem).
Record review of Resident #31's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a
BIMS score of 10, which indicated the resident had moderately impaired cognition.
Record review of Resident #31's Care Plan initialed 10/13/21 revealed, resident had cardiac disease
related to CAD and HTN. Interventions: administer medication per physician orders.
Record review of Resident #31's order summary report for December 2023 revealed a start date for
Lisinopril 20 mg 1 tab po qd was started on 09/02/23, and the parameter read hold if SBP below 110.
Metoprolol Tartrate 50 mg 1 tab po qd hold for SBP less than 110, DBP less 60, and HR less 60.
Record review of Resident #31's MAR for December 2023 did not reveal any area to document the vital
signs.
During medication pass observation on 12/13/23 at 8:35 a.m., MA B was about to administer Lisinopril 20
mg and Metoprolol Tartrate 50 mg to Resident #31 without checking the residents blood pressure. The state
surveyor stopped the medication aide before administration.
During an interview on 12/13/23 at 8:38 a.m., M A B said she did not check Resident #31's blood pressure
because when she started working in the facility three months ago, she told the nurse who was on duty,
there was no area in MAR for documenting Resident #31's blood pressure and heart rate. MA B said the
nurse told her not to take Resident #31's blood pressure because Resident #31 was on blood pressure
medication for maintenance. MA B said the nurse no longer works for the facility.
During an interview on 12/13/23 at 8:41 a.m., the Interim DON said MA B should check Resident #31's
blood pressure before she administered blood pressure medication and documented it on the MAR. The
interim DON said if the blood pressure medication had a perimeter, there should be an area in the MAR for
documentation.
During an observation on 12/13/23 at 8:49 a.m., MA B checked Resident #31's blood pressure on her
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 15 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
right wrist, and Resident #31's blood pressure was 102/50with a pulse of 87.
Level of Harm - Minimal harm
or potential for actual harm
During an observation on 12/13/23 at 8:51 a.m., MA B rechecked Resident #31's blood pressure with an
electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure
was 144/93, and her pulse was 69.
Residents Affected - Few
During an observation on 12/13/23 at 8:55 a.m., LVN J checked Resident#31's blood pressure with an
electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure
was 97/71, and pulse was 63.
During an observation on 12/13/23 at 9:00 a.m., LVN J checked Resident #31's blood pressure with an
electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure
was 109/55 and pulse was 63.
During an interview on 12/13/23 at 9:02 a.m., LVN J said Resident #31's blood pressure medication would
be held because the blood pressure was below the parameter. LVN J said if MA B had given the blood
pressure medications to Resident#31, it would have caused Resident #3's blood pressure to drop more,
which could have made the resident dizzy or even fall. LVN J said she was not aware MA B was not
checking Resident #31's blood pressure before she gave blood pressure medication, and she did not tell
MA B not to check Resident #31's vitals. LVN J said she monitored MA B during medication administration
when she made random rounds, and the DON monitored the nurses when she made random rounds.
During an interview on 12/13/23 at 9:08 a.m., MA B said she would have given the medication without
checking Resident #31's blood pressure if the state surveyor had not intervened. MA B said Resident #31's
blood pressure could have dropped very low if she had given the blood pressure medications because it
was already below the parameter. MA B said Resident #31 could have had a negative outcome. MA B said
the floor nurse does monitor the medication aides during medication administration. She said she had a
skills check-off, and it included checking the resident's blood pressure before administering blood pressure
medication.
During an interview on 12/14/23 at 9:04 a.m., the Interim DON said Resident #31's blood pressure was low,
and if MA B administered BP medications to Resident #31, it could drop the BP even lower. The interim
DON said the negative outcome for Resident #31 could be dizziness and weakness. The interim DON said
if Resident #31's blood pressure medication had a parameter, then MA B should have checked blood
pressure before administering medication. The interim DON stated the incident with
Resident #31 could have the potential for significant medication error because MA B would have
administered the blood pressure medications to Resident #31 without checking her blood pressure, which
was already low if the surveyor had not intervened.
During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills
check off for the nurses and medication aides.
Record review of the undated facility policy on medication administration read in part . facility staff should
observe the six medication rights . right documentation for each resident . a triple check of these 5 rights is
recommended . if there is any other reason to question . or directions, the physician's orders are checked .
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 16 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were
stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication aide
cart, 1 of 1 medication room refrigerator, and 1 of 1 nurse's carts reviewed for medications.
-1 of 1 medication aide cart had two opened undated eye drops and two discontinued medications.
-1 of 1 medication rooms had a water bottle(Ozarka) 700ml sport cover in the freezer section of the
refrigerator.
-1 of 1 nurse's medication cart had opened and undated medications.
These failures could affect residents, placing them at risk for altered effectiveness of the medication and
worsening of the resident's symptoms, requiring medical intervention.
The findings include:
During an observation on 12/13/23 at 2:20 p.m., it revealed the medication aide cart had two eye drop
containers that were opened and not dated: Latanoprost sol 0.005% and Combigan sol 0.2/0.5%.
During an interview on 12/13/23 at 2:20 p.m., MA B said she was not the person who opened the eye
drops. MA B said when a medication aide opened an eye drop container, she should date the container
with the opened date to prevent staff from administering the drops to residents past the expiration date. MA
B said if any staff administered the medication past the open date, the drug might not be effective, and the
resident would not get the desired outcome. MA B said she did not know how long the eye drops should be
used after opening them.
During an observation on 12/13/23 at 2:35 p.m., revealed the medication aide's cart had two discontinued
medications: Clopidogrel 75 mg and Metoprolol [NAME] 25mg were left in the cart.
During an interview on 12/13/23 at 2:35 p.m., MA T said the doctor discontinued medications because the
resident brought them from home, and it was replaced with the medicines provided by the facility. MA T said
the staff should have taken the discontinued medication from the cart and placed it in the box in the
medication room.
During an observation of the medication room on 12/13/23 at 3:00 p.m., revealed the refrigerator in the
medication room had a water bottle (Ozarka) 700ml sports cover in the freezer section of the fridge.
During an interview on 12/13/23 at 3:00 p.m., MA T said the refrigerator should have only the residents and
facility medications, no personal food or drinks from the staff to prevent cross-contamination.
During an interview on 12/13/23 at 3:18 p.m., LVN R said the refrigerator in the medication room was for
medication only, not for any staff personal items, to prevent cross-contamination.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 17 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676470
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caraday of Houston
6534 Stuebner Airline Road
Houston, TX 77091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 12/13/23 at 3:20 p.m., LVN J said the water bottle should not be in the refrigerator
because it was used for medications only, and staff personal items are not stored in it because of infection
control.
During an observation of the nurse's medication cart on 12/13/23 at 3:30 p.m., revealed the following
medications were open and not dated: 2 Insulin lispro injection 100unit, BREO Ellipta 200/25 mcg,
Levalbuterol inhalation solution USP 25 vials in a foil packet, and 4 of the vials was not inside the foil
packet.
During an interview on 12/13/23 at 3:32 p.m., LVN R said all open insulins and breathing treatments should
be dated to prevent administering a medication that had passed the opened expiration date. LVN R said if
the medication was administered to the resident after the medication had passed the expiration date, the
medication would not provide the expected outcome. LVN R said it could have a negative effect on the
resident. LVN R said the breathing treatments should be stored in the foil package to protect the medication
from light. She said she had skills check offs, and medication administration and storage were part of the
check-offs. LVN R said it was the nurse's responsibility to date medicines when opened and remove
medication without a date from the medication cart. LVN R said The DON monitored the nurses when she
did random cart checks.
During an interview on 12/13/23 at 3:55 p.m., the Interim DON said the nurses should remove the
medication the resident came with once the medication from the pharmacy comes in. The Interim DON said
the eye drop container should be labeled with the opened date because once eye drop medicine was
opened, it had an expiration date.
During an interview on 12/13/ at 3:59 p.m., the Interim DON said staff personal items (water and food)
should not be kept in the medication refrigerator in the medication room because of cross-contamination.
During an interview on 12/13/23 at 4:01 p.m., the Interim said the insulin pen, BREO inhaler, and eye drops
should be labeled with the open date so the staff would only use them up to the expiration date to prevent
any adverse outcome.
During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills
check off for the nurses and medication aides.
Record review of the facility policy on medication storage not dated policy read in part, . facility staff should
place open on date to medications label for medications with limited expiration date upon opening . food is
not stored with refrigerated medications .
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676470
If continuation sheet
Page 18 of 18
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the December 14, 2023 survey of Caraday of Houston?
This was a inspection survey of Caraday of Houston on December 14, 2023. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Caraday of Houston on December 14, 2023?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.