Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Cedar Bayou during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities exhibited significant nighttime behavioral changes, including yelling, refusing care, and repeatedly attempting to get out of bed and crawl onto the floor. Staff placed a mattress on the floor for the resident to sleep on and documented that she would not stay in bed and was observed resting on the floor mattress. The following day, an LVN and CNA repeatedly observed the resident on the floor mattress, allowed her to continue sleeping there, and did not verify or ensure that the physician or MPOA had been notified of the behavior change or the mattress-on-floor intervention. Family members later reported they were not informed by staff that the resident was sleeping on the floor, and facility leadership and nursing staff acknowledged that the physician and family should have been notified of these changes, consistent with the facility’s Resident Rights policy requiring notification of changes in condition.
Surveyors determined that the facility failed to complete and share a baseline care plan for a newly admitted, cognitively impaired resident with multiple comorbidities (PVD, CHF, aphasia, DM2, hemiplegia, cerebral infarction, ESRD). The resident had an MPOA on file, but the baseline care plan, signed by the ADON, contained no documented preferences, including the resident’s stated need to sleep sitting upright rather than lying flat. The MPOA reported not receiving a summary of the baseline care plan. The DON stated that baseline care plans should be completed with a representative when a resident is cognitively impaired and acknowledged that omitting preferences and not providing a copy could lead to missed communication and lack of care. The Administrator acknowledged that the representative should have been involved and that a summary should have been provided per facility policy, which requires giving the resident and representative a baseline care plan summary with goals, meds, diet, services, and key health and safety information.
A resident with multiple chronic conditions experienced a significant decline, including low blood pressure, hypoglycemia, and increased lethargy. Despite abnormal vital signs and family concerns, nursing staff did not promptly notify the physician or document the changes as required. The resident was eventually hospitalized in critical condition with multiple organ failure.
A resident with diabetes mellitus and congestive heart failure experienced a significant decline in condition, including persistent hypotension, lethargy, and hypoglycemia, which was not promptly identified or addressed by nursing staff. Despite abnormal vital signs and repeated concerns from the resident and family, staff failed to follow care protocols and physician orders for monitoring and intervention, resulting in the resident's emergency hospitalization for multiple critical conditions.
A resident with diabetes had a critically high blood glucose reading, and the LVN administered insulin per the sliding scale but did not notify the PCP as required by physician orders and the care plan. There was no documentation of physician notification, and the DON was unaware of the incident until later. The facility's policy required prompt physician notification for such changes, which was not followed.
A resident with multiple comorbidities was administered Hydrocodone-Acetaminophen (Norco) after hospital discharge instructions had discontinued the medication. Due to failures in medication reconciliation and documentation, the resident received two doses of Norco within two hours instead of the prescribed six-hour interval. The resident became lethargic, experienced nausea and vomiting, and ultimately died after being transferred to the hospital for severe respiratory distress and cardiac arrest.
A resident with multiple comorbidities received Hydrocodone-Acetaminophen after it was discontinued post-hospitalization, due to failure to update the medication order and improper documentation. The resident was administered the narcotic more frequently than prescribed, became lethargic, experienced nausea and vomiting, and later died after being sent to the hospital. Staff did not reconcile hospital discharge orders with facility records, leading to a critical medication error.
A resident with multiple comorbidities received Hydrocodone-Acetaminophen after it had been discontinued, due to a failure to update the medication order in the chart. The medication was administered more frequently than prescribed, with inconsistent documentation between the eMAR and narcotic log. The resident developed lethargy, nausea, vomiting, and decreased responsiveness, ultimately experiencing respiratory distress and cardiac arrest, and expired at the hospital. Staff interviews and record reviews identified failures in medication reconciliation, documentation, and communication with the physician.
A resident with a history of chronic gout and other conditions was not provided with prescribed pain medication upon admission, despite repeated complaints of severe pain. The facility staff failed to follow up with the pharmacy and did not document or address the resident's pain, leading to an Immediate Jeopardy situation.
A resident with chronic gout, metabolic encephalopathy, type 2 diabetes mellitus, and stroke did not receive prescribed medications, including Eliquis and Hydrocodone-Acetaminophen, upon admission and for two days thereafter. Despite the medications being available, the facility failed to administer them, resulting in the resident experiencing continued pain and frustration.
A resident with significant cognitive impairment alleged that an LVN kicked her after she had fallen in her restroom. The facility's investigation confirmed that the LVN used her foot to restrain the resident, which was deemed abusive. The incident caused the resident pain and fear, and the LVN was terminated. The facility conducted in-service training for all staff on abuse, neglect, and exploitation following the incident.
A resident with severe cognitive impairment eloped from the facility despite wearing a wander guard. The facility failed to provide consistent one-to-one monitoring and did not adequately secure exit doors, leading to the resident being found across the street by law enforcement. Staff acknowledged lapses in procedure adherence and communication.
The facility failed to implement a baseline care plan for a newly admitted resident within 48 hours of admission. The resident, with multiple diagnoses including metabolic encephalopathy and type 2 diabetes, did not have a completed baseline care plan, which was confirmed by the MDS LVN and the DON. This failure could result in the resident not receiving necessary care and services.
The facility failed to document the use of a scoop mattress in a resident's care plan, despite the resident's high risk of falling and history of falls. This omission could lead to inconsistencies in care and place the resident at risk of not attaining or maintaining their highest practicable well-being.
A facility failed to maintain a medication error rate below 5%, resulting in a 6% error rate. A medication aide did not administer Sevelamer Carbonate and Carvedilol with meals as required, affecting a resident with hypertension and chronic kidney disease. Observations and interviews confirmed the medications were given without food, contrary to physician orders.
The facility failed to ensure that the dumpster lids and doors were secured, as observed with a commercial-size dumpster left completely open. Staff interviews confirmed that the dumpster should be closed to prevent trash from coming out and to keep unwanted items out. The Administrator expects the dumpster to be closed to avoid attracting pests. The facility did not provide their waste disposal policy before the exit interview.
Failure to Notify Physician and MPOA of Resident’s Behavioral Change and Mattress-on-Floor Intervention
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and medical power of attorney (MPOA) when there was a deterioration in the resident’s physical and mental status. The resident was an elderly female with multiple serious diagnoses, including peripheral vascular disease, heart failure, aphasia, type 2 diabetes mellitus, hemiplegia, cerebral infarction, and end stage renal disease. Her MDS showed a BIMS score of 00, indicating severe cognitive impairment. On admission, an RN documented that the resident was awake, alert, oriented x1, uncooperative, and combative. The baseline care plan behavioral section was blank, and the record contained an MPOA document naming two family members as healthcare agents. On the night in question, staff reported that the resident was up all night yelling, refusing care, and repeatedly attempting to get out of bed and crawl onto the floor. CNA G stated that the resident was difficult, would not stay in bed, and crawled down to the floor where she was restless and constantly tried to move around. A mattress was placed on the floor at the bedside so that the resident would not land hard on the floor, and an RN documented in an admission summary addendum that the mattress was left on the floor because the resident would not stay in bed and was observed sleeping on the mattress, appearing content there. Despite these significant behavioral changes and the use of a mattress on the floor as an intervention, there was no documentation that the physician or the resident’s representative was notified of the overnight behavior or the decision to have the resident sleep on a mattress on the floor. During the following day shift, LVN B received report from the night nurse that the resident had been up all night yelling and trying to get out of bed. On morning rounds, LVN B observed the resident resting quietly on the mattress on the floor and later documented that the resident remained resting, was compliant with wound care, and denied discomfort. CNA C reported checking on the resident multiple times, observing her breathing and appearing calm, and leaving the breakfast tray in the room after being instructed by LVN B to let the resident sleep. LVN B acknowledged she did not know whether the resident had an MPOA and did not verify whether the physician or representative had been notified of the overnight behavior or the mattress on the floor. Later that day, LVN B documented a change in condition: the resident was slow to respond, had audible moaning, required CPR, and was transferred to the emergency room after a weak, thready pulse and inability to obtain a blood pressure. Family interviews confirmed that the resident’s MPOA and another family member were not informed by facility staff about the resident’s restless nighttime behavior or that she was sleeping on a mattress on the floor. The MPOA stated he had visited the resident the prior evening and found her sitting in a wheelchair, smiling, and appearing fine, and that he only learned from another family member that the resident was on the floor. Facility leadership and nursing staff, including the ADON, DON, and RN D, stated that the physician and family should have been notified of the resident’s nighttime behavior, aggressiveness, inability to sleep, and the use of a mattress on the floor, and that they would have expected such notification for a change in condition. The facility’s Resident Rights policy stated that residents have the right to be notified of their medical condition and any changes in their condition. The surveyors concluded that the facility failed to immediately consult with the resident’s physician and representative when there was a deterioration in the resident’s physical and mental status, specifically regarding her restless nighttime behavior, repeated attempts to get out of bed, and the need for a mattress on the floor.
Failure to Complete and Share Baseline Care Plan Including Resident Preferences
Penalty
Summary
Surveyors found that the facility failed to develop and implement a complete baseline care plan and to provide a summary copy to the resident’s representative for one cognitively impaired resident. The resident was an elderly female admitted with multiple serious diagnoses, including peripheral vascular disease, heart failure, aphasia, type 2 diabetes mellitus, hemiplegia, cerebral infarction, and end stage renal disease. Her MDS showed a BIMS score of 00, indicating severe cognitive impairment, and her medical record contained an MPOA document naming a primary and secondary healthcare agent. Review of the baseline care plan, signed by the ADON, showed no entries under the section for additional comments or preferences. During interviews, the resident’s MPOA stated that the resident did not like to lie flat and preferred to sleep sitting upright, and that she could answer yes/no questions. He also stated he did not receive a summary copy of the baseline care plan. The DON stated that baseline care plans should be completed with a resident’s representative when the resident is cognitively impaired and acknowledged that not including preferences and not providing a copy to the representative could lead to missed communication and lack of care. The Administrator stated that a summary copy of the baseline care plan would be given to the resident or representative only if requested, and then acknowledged that the representative should have been included in the baseline care plan creation and that a summary should have been provided per facility policy. Facility policy required providing the resident and representative with a summary of the baseline care plan including initial goals, medications, dietary instructions, services and treatments, and information to properly care for the resident upon admission and address specific health and safety concerns.
Failure to Notify Physician of Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's condition. The resident, an older adult with a history of coronary artery disease, heart failure, hypertension, diabetes mellitus, and other chronic conditions, exhibited declining vital signs over several days, including persistently low blood pressure, low oxygen saturation, and episodes of hypoglycemia. Despite these abnormal findings, there was no timely physician notification or appropriate intervention documented by the nursing staff. The resident was noted to be increasingly lethargic, sleeping more than usual, and experiencing confusion and weakness. Family members expressed concern about the resident's condition and reported difficulty reaching him by phone. Nursing documentation indicated that the resident's blood pressure readings were repeatedly below normal, and his blood sugar dropped to hypoglycemic levels. However, staff did not consistently document these changes as a change in condition, nor did they promptly notify the physician as required by facility policy. Interviews with staff revealed a lack of awareness regarding the resident's diabetic status and confusion about when to notify the physician for abnormal vital signs. Ultimately, the resident's condition deteriorated to the point of requiring emergency transfer to the hospital, where he was found to be in acute hypoxic and hypercapnic respiratory failure, septic shock, acute renal failure, and persistent hyperglycemia. The hospital records indicated that the resident was critically ill with vital organ impairment or failure. The failure to recognize and act upon the resident's significant change in condition, including not notifying the physician in a timely manner, directly contributed to the severity of the resident's health crisis.
Failure to Identify and Respond to Acute Change in Condition in Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards of practice for a resident with multiple complex medical conditions, including diabetes mellitus and congestive heart failure. The facility did not properly identify or intervene in the resident's acute change in condition, despite clear evidence of declining vital signs and symptoms such as persistent hypotension, lethargy, and altered mental status over a period exceeding 24 hours. Nursing staff documented low blood pressure readings, low oxygen saturation, and changes in the resident's behavior, such as increased sleepiness and confusion, but did not consistently notify the physician or take appropriate action in a timely manner. The resident's care plan and physician orders required regular monitoring of blood glucose and blood pressure, with specific parameters for holding medications and notifying the physician of abnormal findings. However, blood sugar checks were not performed as ordered, and staff failed to recognize or respond to signs of hypoglycemia and hypotension. Interviews revealed that both the resident and family members repeatedly expressed concerns about the resident's condition and requested blood sugar checks, but these concerns were not adequately addressed by nursing staff. Documentation gaps were also noted, with missing nursing notes and incomplete follow-up on abnormal vital signs. The situation escalated when the resident's condition deteriorated further, resulting in critical laboratory findings and the need for emergency transfer to the hospital, where the resident was diagnosed with hypoglycemia, hyperkalemia, acute renal failure, septic shock, and respiratory failure. The delay in recognizing and responding to the resident's acute change in condition, as well as the failure to follow established care protocols and physician orders, directly contributed to the deficiency identified by surveyors.
Failure to Notify Physician of Critically Elevated Blood Glucose
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with diabetes mellitus. The resident had physician orders and a care plan that required notification of the primary care provider (PCP) if blood glucose levels exceeded 401 mg/dL. On 6/9/2025, the resident's blood sugar was recorded at 403 mg/dL by an LVN, who administered the prescribed insulin dose but did not notify the PCP as required by both the care plan and physician orders. There was no documentation in the nursing notes or 24-hour report binder indicating that the PCP was notified of the elevated blood sugar level. Interviews revealed that the DON was unaware of the incident until after the fact and confirmed that the PCP should have been notified immediately. The LVN involved stated she was new and had not fully read the order, resulting in the failure to notify the PCP. The PCP confirmed he was not notified and would have provided further instructions if contacted. The facility's policy required prompt notification of the physician for changes in a resident's condition, including specific instructions to notify the physician, which was not followed in this case.
Failure to Discontinue and Appropriately Administer Narcotic Medication Leads to Resident Death
Penalty
Summary
A resident with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, and dependence on dialysis, was readmitted to the facility following a hospital stay. Upon return, the hospital discharge summary included an order to discontinue Hydrocodone-Acetaminophen (Norco) due to concerns about generalized weakness, and this was noted in the resident's nursing notes. However, the Norco order was not discontinued in the facility's electronic medical record (eMAR), and the medication remained available for administration. On the day of the incident, the resident received two doses of Norco within a two-hour period, rather than the prescribed six-hour interval. The first dose was administered by one LVN and documented in the narcotic log but not in the eMAR. The second dose was given by another LVN, who, unaware of the previous administration, provided the medication again when the resident requested pain relief. This resulted in the resident receiving Norco more frequently than ordered. The error was later identified, and the physician was notified, who advised monitoring the resident. Documentation shows the resident became increasingly lethargic, experienced nausea and vomiting, and had a significant decline in responsiveness throughout the day. Despite monitoring and physician notification, the resident's condition continued to deteriorate, with vital signs indicating hypotension and decreased oxygen saturation. The resident was eventually transferred to the hospital due to severe respiratory distress, where she experienced cardiac arrest and expired. Interviews with staff revealed lapses in medication reconciliation, documentation, and adherence to physician orders, as well as failures to properly discontinue medications per hospital discharge instructions and to ensure accurate communication between shifts.
Failure to Discontinue and Accurately Administer Narcotic Medication Leads to Resident Death
Penalty
Summary
A deficiency occurred when the facility failed to provide proper pharmaceutical services, resulting in a resident receiving Hydrocodone-Acetaminophen (Norco) after it had been discontinued following a hospital visit. The medication was not discontinued in the resident's chart, and the resident received Norco more frequently than the order allowed. Documentation showed that the resident was administered Norco two hours apart instead of the prescribed six-hour interval, and the medication was not properly documented in the electronic Medication Administration Record (eMAR), leading to a double dosing incident. The resident involved was an elderly female with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, dependence on dialysis, and chronic embolism and thrombosis. She was cognitively impaired and required assistance with activities of daily living. After returning from the hospital, her discharge instructions included discontinuation of Norco, but this was not reflected in her medication orders at the facility. As a result, she received Norco doses inappropriately, which was noted by staff when she became lethargic, drowsy, and experienced nausea and vomiting. Her condition deteriorated throughout the day, and she was eventually transported to the hospital, where she expired from cardiac arrest. Interviews and record reviews revealed that staff failed to reconcile hospital discharge orders with the facility's medication records, did not discontinue the medication in the system, and did not document administration properly in both the eMAR and narcotic log. There was confusion among staff regarding the resident's medication orders, and the lack of proper documentation and communication led to the administration of a discontinued and potentially harmful medication. The facility's policies required proper documentation and reconciliation of medication orders, but these were not followed, resulting in a critical medication error.
Failure to Prevent Significant Medication Error Leading to Resident Harm
Penalty
Summary
A significant medication error occurred when a resident received Hydrocodone-Acetaminophen (Norco) after it had been discontinued following a hospital visit. The discontinuation order was not properly entered into the resident's chart, resulting in the medication remaining active in the facility's records. Subsequently, the resident was administered Norco more frequently than the prescribed interval, with doses given two hours apart instead of the ordered six-hour interval. Documentation of medication administration was inconsistent, with one dose recorded in the narcotic log but not in the electronic medication administration record (eMAR), leading to a double dosing event. The resident involved was an elderly female with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, dependence on dialysis, and chronic embolism and thrombosis. Upon readmission from the hospital, her discharge instructions included discontinuation of Norco, but this was not reflected in the facility's medication orders. The resident exhibited symptoms of lethargy, nausea, vomiting, and decreased responsiveness following the medication error. Staff noted the overdose and monitored the resident, but her condition deteriorated throughout the day, culminating in respiratory distress and eventual cardiac arrest. She was transported to the hospital, where she expired later that evening. Interviews and record reviews revealed lapses in medication reconciliation, documentation, and adherence to physician orders. Staff failed to ensure that discontinued medications were removed from the active medication list and did not consistently document administration in both the eMAR and narcotic log. There was also a lack of timely and effective communication with the physician regarding the resident's change in condition and the medication error. These failures directly contributed to the resident receiving a discontinued medication at an unsafe frequency, resulting in a significant adverse event.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services. Upon admission, the resident was prescribed Hydrocodone-Acetaminophen 10-325mg for pain, but the medication was not administered until several days later. During this period, the resident repeatedly complained of severe pain, which was documented by various therapists and staff members. Despite these complaints, there was no nursing documentation concerning the resident's pain, and the prescribed medication was not provided until a physician visited and changed the medication orders. The resident, who had a history of chronic gout, metabolic encephalopathy, type 2 diabetes mellitus, and stroke, was admitted to the facility and experienced significant pain due to a gout flare. The resident expressed that his pain was not being managed, which hindered his ability to participate in therapy. Multiple staff members, including therapists and nurse aides, were aware of the resident's pain but failed to ensure that the prescribed pain medication was administered. The admitting nurse reconciled the medications but did not follow up with the pharmacy, and subsequent nurses did not take appropriate action to address the resident's pain. Interviews with staff revealed a lack of communication and follow-up regarding the resident's pain management. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the facility's pain management policy was not followed, resulting in the resident experiencing unnecessary pain. The facility's failure to administer the prescribed pain medication and properly assess and document the resident's pain led to an Immediate Jeopardy situation, which was later addressed through corrective actions.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide routine and emergency drugs for a resident upon admission and for two days thereafter. The resident, who had a history of chronic gout, metabolic encephalopathy, type 2 diabetes mellitus, and stroke, did not receive his prescribed medications, including Eliquis (a blood thinner) and Hydrocodone-Acetaminophen (a pain medication). This resulted in the resident experiencing continued pain and expressing frustration over the lack of proper medication management. The admitting nurse reconciled and entered the resident's medication orders, but there was a failure in the follow-up process to ensure the medications were administered. Despite the medications being available in the facility's electronic dispensing machine, they were not given to the resident. Interviews with the nursing staff revealed a lack of proper follow-up with the pharmacy and physician to address the medication delay, and the resident's pain was not managed effectively. The Director of Nursing (DON) acknowledged the oversight and confirmed that the medications were available but not administered. The resident reported severe pain due to a gout flare and expressed dissatisfaction with the facility's handling of his medication routine. The failure to administer the prescribed medications as ordered led to the resident experiencing unnecessary pain and a decline in his quality of life.
Resident Abuse by LVN
Penalty
Summary
The facility failed to ensure that a resident remained free from abuse, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) and a resident with significant cognitive impairment. The resident, who had a history of falls and multiple medical conditions including dementia and major depressive disorder, alleged that the LVN kicked her in the side or back after she had fallen in her restroom. This incident was corroborated by another staff member who witnessed the LVN using her foot to restrain the resident and making verbally abusive comments. The resident reported feeling pain and fear as a result of the incident and expressed concerns about being hurt again by other staff members. The facility's internal investigation confirmed that the LVN had used her foot to restrain the resident, which was deemed inappropriate and abusive. The LVN admitted to using her foot to hold the resident down but denied kicking her. The investigation also revealed that the LVN had a history of training on abuse prevention, yet still engaged in behavior that constituted abuse. The facility's abuse policy clearly stated that residents should be free from any type of abuse, and the LVN's actions were in direct violation of this policy. Interviews with other residents and staff members indicated that while most did not have concerns about abuse, the incident with the LVN and the resident was an isolated but serious event. The facility conducted in-service training for all staff on abuse, neglect, and exploitation following the incident. However, the deficiency was identified as posing a risk for abuse, pain, fear, and psychosocial impairment for the residents, highlighting a significant lapse in ensuring a safe environment for all residents.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who eloped from the facility without staff knowledge, despite wearing a wander guard. The resident, who had a history of severe cognitive impairment and multiple medical conditions, was found across the street by law enforcement and returned to the facility. The resident's care plan included interventions for elopement risk, but these were not effectively implemented, leading to the incident. The resident's wander guard was not consistently checked for function, and the facility exit doors were not adequately secured to prevent elopement. Staff interviews revealed that the resident was supposed to be on one-to-one monitoring, but due to staffing shortages, this was not consistently provided. Additionally, the facility's exit doors, except for the front door, did not have alarms that would alert staff to an elopement. Observations and interviews indicated that staff were not always present to monitor the resident, and there were lapses in communication and procedure adherence. The facility's Director of Nursing (DON) and other staff acknowledged these failures, and the facility was found to be out of compliance, posing a risk of serious injury to residents due to lack of supervision.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to implement a baseline care plan for a newly admitted resident within 48 hours of admission. The resident, a [AGE] year-old male with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, stroke, and chronic gout, was admitted on [DATE]. However, no baseline or comprehensive care plan was completed for him. Interviews with the MDS LVN and the DON confirmed that the baseline care plan, which should have been completed within 48 hours, was not done. The incomplete baseline care plan was highlighted in yellow, lacked signatures, dates, and data, indicating it was not completed. The MDS LVN and the Administrator both emphasized the importance of the baseline care plan in ensuring continuity of care and meeting the resident's immediate needs. The facility's policy requires that a baseline care plan be completed within 48 hours of admission, including initial goals, physician orders, dietary orders, therapy services, social services, and PASARR if applicable. The failure to complete this plan could result in the resident not receiving the necessary care and services for health promotion and continuity of care.
Failure to Document Use of Scoop Mattress in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #57, which included the use of a scoop mattress. This deficiency was identified through observation, interview, and record review. The care plan did not document the use of the scoop mattress, which is intended to prevent falls or minimize the likelihood of falls. This omission could place the resident at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Resident #57, a [AGE] year-old woman, was admitted with multiple diagnoses including encephalopathy, cirrhosis of the liver, cerebral infarction, Parkinson's Disease, hypertension, aphasia, dysarthria, muscle weakness, difficulty walking, lack of coordination, cognitive communication deficit, and a displaced avulsion fracture of the left hip. The resident had a history of falls and was assessed as having a high risk of falling. Despite this, the care plan did not include any focus or intervention related to the use of a scoop mattress. Interviews with various staff members, including the ADON, MDS LVN, and DON, revealed that they were unaware of how long Resident #57 had been using the scoop mattress. They acknowledged that the use of a scoop mattress should be documented in the care plan to ensure all staff are aware of the necessary interventions. The failure to update the care plan with this critical information could lead to inconsistencies in the care provided to Resident #57, as staff may not know to obtain a scoop mattress prior to assisting the resident into bed.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in a medication error rate of 6%. This was based on 2 errors out of 32 opportunities, involving one resident. Specifically, a medication aide (MA Q) did not administer Sevelamer Carbonate and Carvedilol to a resident as ordered by the physician, which required these medications to be given with meals. The resident, who had diagnoses including hypertension and chronic kidney disease, did not receive these medications with food as required, potentially affecting the therapeutic efficacy and safety of the medications. The resident's care plan and medication administration records indicated that Sevelamer Carbonate was to be given with meals to act as a phosphorus binder, and Carvedilol was to be given with food to slow absorption and prevent rapid blood pressure drops. Observations revealed that the medications were administered without food, and interviews with the resident and MA Q confirmed this practice. The resident had not eaten at the time of medication administration, and MA Q admitted to not following the specific instructions to give the medications with food. Interviews with the Director of Nursing (DON), the facility's Quality Assurance Pharmacist, and the Dialysis RN further confirmed the importance of administering these medications with food. The DON and the pharmacist highlighted the risks of not following the administration instructions, such as potential stomach upset and improper medication absorption. The Dialysis RN emphasized that Sevelamer needs food in the stomach to effectively bind phosphorus, preventing complications like weak bones due to high blood phosphorus levels.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly by not ensuring that the dumpster lids and doors were secured. This was observed on 02/09/2024 at 8:02 AM, when the facility's dumpster area had a commercial-size dumpster with the top lid completely open. During an interview on 02/12/2024 at 8:45 AM, DA BB stated that kitchen and housekeeping staff are responsible for taking trash to the dumpster and acknowledged that the dumpster should be closed when not in use, but sometimes it is not. Another interview on 02/12/2024 at 9:03 AM with HKM confirmed that the dumpster should be closed to prevent trash from coming out and to keep unwanted items out. The Administrator, interviewed on 02/12/2024 at 9:30 AM, also stated that she expects the dumpster to be completely closed to avoid attracting pests. The facility did not provide a copy of their policy and procedure for Waste Disposal/Dumpster before the exit interview.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baytown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rollingbrook Rehabilitation And Healthcare Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Focused Care At Allenbrook | 0.8 mi | ★★★★★ | 4 | 1 |
| Focused Care At Burnet Bay | 1.2 mi | ★★★★★ | 4 | 0 |
| Mont Belvieu Rehabilitation & Healthcare Center | 1.3 mi | ★★★★★ | 9 | 0 |
| St James House Of Baytown | 2.6 mi | ★★★★★ | 9 | 0 |
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