Houston Transitional Care: Infection Control Failures - TX
The residents most at risk were among the most medically vulnerable in the building: people with Foley catheters, intravenous ports and lines, and other artificial openings in their bodies. The facility had placed these residents on Enhanced Barrier Precautions precisely because of that vulnerability. The precautions require staff to wear gloves and disposable gowns during direct care and to change them between residents. The nursing assistant, identified in the inspection report as CNA A, was not doing that.
CNA A had been working at the facility for nearly five months, full time, on 12-hour shifts from 7 AM to 7 PM. When inspectors interviewed her on the morning of May 28, she said she had received in-service training on infection control. She could not recall whether that training had covered Enhanced Barrier Precautions specifically. She acknowledged that moving between rooms with gloves on placed residents at risk of infections.
The director of nursing, who also served as the facility's Infection Control Preventionist, was interviewed the same morning. She described exactly what the precautions were supposed to accomplish: staff should wear gloves and gowns during direct care for residents on Enhanced Barrier Precautions, practice hand hygiene before and after caring for each resident, and never travel from room to room in the same gloves. The DON said plainly that failing to take those precautions would put residents at risk of infections.
That is the same conclusion CNA A had reached when inspectors asked her about it.
The facility's own policies, reviewed by inspectors, reinforced both of them. A hand hygiene policy revised in October 2023 listed the moments when hand hygiene was required: immediately before touching a resident, after touching a resident, after contact with the resident's environment, and immediately after removing gloves. An Enhanced Barrier Precaution policy, revised as recently as December 2024, described the purpose of the precautions as preventing the spread of multi-drug resistant organisms, and required targeted gown and glove use during high-contact care activities.
The gap between those written policies and what CNA A was actually doing in the hallways was what inspectors documented.
Multi-drug resistant organisms are bacteria that have developed resistance to the antibiotics commonly used to treat them. They spread through contact, including contact carried on the surface of gloves. Residents with catheters, IV lines, and open surgical sites have direct pathways into their bloodstream and internal tissue that healthy skin would otherwise block. For those residents, a contaminated glove touching their care site is not a theoretical risk.
Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. The complaint inspection covered two pages.
What the report does not say is how long CNA A had been working this way, how many residents she had moved between on how many shifts, or whether anyone had noticed before a complaint was filed. The DON knew the standard. The policy had been updated five months before the inspection. CNA A had been on the floor for nearly as long as that updated policy had been in place.
She said the training she received did not clearly cover Enhanced Barrier Precautions. Nobody at the facility appears to have caught the gap until an inspector arrived to look for it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Houston Transitional Care from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
HOUSTON TRANSITIONAL CARE in HOUSTON, TX was cited for violations during a health inspection on May 28, 2026.
The facility had placed these residents on Enhanced Barrier Precautions precisely because of that vulnerability.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.