Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to promote and facilitate resident self- determination through
support of resident choice for 1 of 6 residents (CR#1) reviewed for resident rights. The facility failed to
ensure that CR#1had the opportunity to exercise rights regarding those things that were important in their
life. The facility failed to promote self-determination by not having hot water in the facility, which prevented
each from taking showers. This failure could place residents at risk of decreased self-worth due to their
preferences not being met.The findings include: Record Review of CR#1's face sheet revealed a [AGE]
year-old male who was admitted to the facility on [DATE] and discharged on 10/21/25 with diagnoses of
Cerebral Infarction (Stroke), COPD (lung disease), Viral Hepatitis C (Liver Damage), and Type 2 Diabetes
(Increase sugar levels). Record Review of CR#1's MDS Quarterly dated 9/19/25 revealed a BIMS score of
15 (which means CR#1 had normal cognitive functioning). CR#1 had impairment on one side (upper and
lower extremities) and used a wheelchair for mobility; CR#1 needs partial/moderate assistance from staff
for shower/bathing, which includes transferring in/out of the tub/shower. Record Review of CR#1's care plan
dated 4/4/25 revealed: Problem: CR#1 has an ADL self-care performance deficit r/t impaired mobility. Date
initiate 4/4/25. Rev. 5/7/25.Goal: CR#1 will maintain current level of function in through the review date. Date
initiate 4/4/25. Rev. 5/7/25. Target: 10/25/25.Interventions: Bathing/Showering: CR#1 requires (limited to
extensive) by (1) staff with shower. Date initiate 4/4/25. Rev. 8/20/25. Contractures: CR#1 has contractures
of the left hand. Provide skin care, washing and drying hand to keep clean and prevent skin breakdown.
Date initiate 4/4/25. Rev. 8/20/25. Record Review of Nursing Notes (administration Note) dated 8/5/25 at
11:05 a.m., by RN revealed, Resident complained of not receiving a hot shower due to facility plumbing
problems. Plumbing problems have been resolved as of 8/4/25. Resident offered shower however informed
that the shower temperature is lukewarm. Resident refuses stating quote I will wait as I want a hot shower
and quote at 11:00 AM resident noted to be in hallway after taking recent hot shower. Residents stated
satisfaction after hot shower .Record Review of an email from the OMB dated 9/30/25 at 3:00pm to the
Admin revealed the following Correspondence: Good morning Admin, I got a message from resident we
discussed regarding temperature of showers. They are stating that it is running cold and that attendant is
stating that they are refusing a shower. They state they do not want to take a cold shower. Would you kindly
advise? Record Review of email from the Admin to the OMB. dated 9-30-25 revealed the following
Correspondence: The water is not as hot right now because the washers and kitchen is in full use. The
maintenance director was notified and turned the temperature up. After lunch clean up the temperature will
be at its hottest and he can have a shower then. Record review of HHSC complaint dated 8/5/25 revealed,
CR#1 had not showered in several weeks and the facility staff kept saying there was no hot water. 11/20/25
3:00pm Observation Rounds with Maintenance and observed the water temps in five roomsS room [ROOM
NUMBER] - Temp
(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 2
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
11/21/2025
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 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
106S room [ROOM NUMBER] - Temp 106S room [ROOM NUMBER] - Temp 109S room [ROOM NUMBER]
- Temp 102S room [ROOM NUMBER] - Temp 108 During a telephone interview on 11/20/25 at 1:26 p.m.,
RN she stated the facility was always losing hot water in the residential area, specifically showers. RN
stated residents did not get showers or didn't take showers because the water was too cold. She stated
residents complained to the administration and the ombudsman. In an interview on 11/20/25 at 3:22 p.m.,
the Maint,he stated it was a pump that was inoperable that affected the entire building. He stated he was
not here during this issue. He stated on 8/21/25 the circular pump in the boiler room failed and had to be
replaced the same day. He stated the failure created an issue with water temps in other areas of the facility.
He stated the hot water in the kitchen causes the other areas of the facility to have a cold temperature,
which may have included the resident shower areas. During the interview with Maint, the Admin provided
an invoice for plumbing repair. In an interview on 11/20/25 at 4:05 p.m., the Admin stated that the facility is
going through a new organization and when she became aware of the water issue it was addressed
immediately. She stated this issue began under the outgoing corporate ownership, not the current, which
she represented. In an interview on 11/20/25 at 5:34 p.m., Resident #2 stated the hot water was out for
about 3 weeks to a month and she could not bathe or shower because it was too cold. Resident #2 stated
the water is getting hot now. In an interview on 11/20/25 at 5:45 p.m., Resident #3 stated he is doing well.
He stated the hot water was out for about 2-3 weeks. Resident #3 stated the water is getting hot now. In an
interview on 11/20/25 at 6:00 p.m., Resident #4 she stated the hot water was off for about a week, but it
could have been longer, but she was certain it was at least a week. During a telephone interview on
11/21/25 at 3:48 p.m., the OMB stated that the residents are not lying about the water temp. She stated
CR#1 did complain several times about the water amongst other things. She stated while CR#1 was
transferred to another facility there were other residents that complained about the same issue starting on
2/15/25. The OMB stated she addressed it with the facility at that time and most recently and was told that
the problem was resolved with repairs. Record Review of purchase Invoice for boiler part and installation
dated 8/14/25. Record Review of the facility's Resident Rights Policy dated 6/10/25 revealed:4. Respect and
dignity. The resident has the right to be treated with respect and dignity, including:c. The right to reside and
receive services in the facility in the facility with reasonable accommodation of resident or other residents.8.
Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and support for daily living safely. Record review of the Safe
and Homelike Environment policy dated 6/15/25 revealed:1. The Facility will create and maintain, to the
extent possible, home like environment that they emphasizes the institutional character of the setting.3.
Housekeeping and maintenance services will be provided as necessary to maintain the sanitary, ordering
the and comfortable environment.7. The facility will maintain comfortable safe temperature levels.
Event ID:
Facility ID:
676470
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation 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.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
FAQ · About this visit
Common questions about this visit
What happened during the November 21, 2025 survey of Caraday of Houston?
This was a inspection survey of Caraday of Houston on November 21, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Caraday of Houston on November 21, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.