Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Fort Bend Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident with cognitive and mobility impairments experienced an unwitnessed fall resulting in a head injury that required hospital treatment. The incident was not reported to the state or adult protective services as required, despite the resident's inability to communicate how the fall occurred and the seriousness of the injury. Staff interviews confirmed the event was not reported according to regulations.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a deficiency for not following the established care plan.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and directly impacted residents requiring assistance with bowel and bladder management.
A medication cart was found unlocked and unattended, with several opened medications inside that were not dated. The nurse responsible stated she thought the cart was locked, and both the UM and DON confirmed that carts should always be locked when unattended. Facility policy requires medication carts to be locked, but does not address dating of opened medications.
A resident with severe cognitive impairment and a history of falls did not receive a thorough assessment or neuro checks after an unwitnessed fall. Staff failed to perform and document range of motion checks, and pain was inconsistently assessed, leading to a delay in recognizing a hip fracture that required surgery.
A resident with severe cognitive impairment and mobility deficits experienced multiple falls in the dining room, including one with injury, but the care plan was not updated to include targeted fall prevention interventions for that setting. The care plan also lacked specific methods for assessing and monitoring chronic pain in a nonverbal resident, and staff were unfamiliar with appropriate pain assessment strategies. These deficiencies were identified through record review and staff interviews.
A facility was found to have a medication error rate of 6% during a survey, involving two residents and two staff members. One resident did not receive Thiamine due to its unavailability, and another did not receive Metoprolol despite being within the administration parameters. Staff interviews confirmed the errors, with one resident later hospitalized before receiving the missed medication.
The facility failed to maintain accurate records of controlled drugs, as evidenced by incomplete shift counts on the Hall 100 medication cart. The Controlled Drugs-Count Record had blanks that were later filled in by an LVN without explanation. The DON confirmed that controlled medications should be counted by both oncoming and outgoing nurses each shift, and filling in blanks was deemed 'unacceptable.'
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Timely Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately as required. Specifically, an unwitnessed fall involving a resident with significant cognitive and physical impairments was not reported to the State Survey Agency or adult protective services. The resident, who had a history of falls, cognitive communication deficits, and was totally dependent on staff for mobility and activities of daily living, sustained a head injury resulting in significant bleeding and required transfer to a hospital, where she received four stitches. Despite the resident's inability to communicate the circumstances of the fall and the presence of a serious injury, the Director of Nursing (DON) did not report the incident to the state, stating that she did not suspect abuse. The administrator indicated that unwitnessed falls with head injuries should be reported, but in this case, the required reporting did not occur. Staff interviews and record reviews confirmed that the incident was not reported as mandated, and the facility's in-service records showed that staff had received training on abuse and neglect prior to the event.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical orders.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care provided to residents requiring assistance with bowel and bladder management.
Medication Cart Left Unlocked and Opened Medications Not Dated
Penalty
Summary
Surveyors observed that the 100 Hall Nurse medication cart was left unlocked and unattended in the hallway, with no nurse present. Upon returning, the unit manager (UM) acknowledged that she mistakenly left the cart open, believing it had been locked. Further inspection of the cart revealed four opened over-the-counter medications—24-hour Allergy Nasal spray, Latanoprost Sol 0.005%, Geri-Tussin (Guaifenesin), and Milk of Magnesia—none of which were dated to indicate when they had been opened. The UM confirmed that opened medications should be dated and are typically considered effective for 30 days after opening. Interviews with the UM and the Director of Nursing (DON) confirmed that medication carts are required to be locked at all times when unattended, in accordance with facility policy. The DON stated that failure to lock the cart could result in unauthorized access to medications. Review of the facility's policy indicated that medication carts must be locked when out of the nurse's view and when not in use, but the policy did not address the requirement to date opened medications.
Failure to Assess and Monitor After Unwitnessed Fall Resulting in Delayed Diagnosis of Hip Fracture
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls did not receive appropriate assessment and care following an unwitnessed fall in the facility's dining room. The resident, who had diagnoses including dementia, Alzheimer's disease, lack of coordination, and muscle weakness, was found on the floor after a fall. Staff failed to perform a thorough assessment at the scene, including range of motion (ROM) checks, and did not initiate neurological checks as required by facility policy for unwitnessed falls. Documentation was incomplete, with no clear record of ROM assessment or neuro checks, and the incident was not fully detailed in the progress notes. Following the fall, the resident exhibited signs of pain and changes in behavior, such as vocalizing distress and refusing to move her leg during care. Despite these indications, there was a delay in recognizing the severity of her injury. Pain assessments were inconsistently documented, and staff responses varied, with some staff noting pain and others documenting none. The resident remained in bed and was not mobilized, but it was not until the following day that an x-ray was ordered, which revealed a right hip fracture requiring surgical intervention. Interviews with staff revealed confusion and inconsistency regarding the assessment process for unwitnessed falls, including when to perform neuro checks and how to document assessments. The facility's policies required immediate neuro checks and comprehensive assessments for unwitnessed falls, but these were not followed. The lack of timely and thorough assessment, documentation, and follow-up led to a delay in diagnosis and treatment of the resident's hip fracture.
Failure to Revise Care Plan After Falls and Inadequate Pain Assessment for Nonverbal Resident
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was reviewed and revised following a change in condition and after multiple falls for a resident with severe cognitive impairment and significant physical limitations. Despite the resident experiencing three falls in the dining room, including one resulting in a skin tear, the care plan was not updated to include specific interventions to address the risk of falls in that location. The care plan did note a general risk for falls and included standard interventions, but did not reflect the pattern of falls in the dining room or implement targeted strategies to mitigate this risk. Additionally, the facility did not ensure that the resident's care plan included appropriate interventions and methods for assessing and monitoring chronic pain, particularly given the resident's inability to effectively communicate pain. Although the care plan referenced goals for pain management and directed staff to assess for pain, it did not specify the use of validated tools or methods suitable for nonverbal residents. Interviews with staff revealed a lack of familiarity with the care plan's pain management interventions, and staff were unable to describe how they would assess pain in a nonverbal resident, relying instead on general observation and shift reports. The resident involved had a history of dementia, cognitive communication deficits, a recent hip fracture, and required substantial to maximal assistance with activities of daily living. Physical therapy assessments documented significant mobility and balance impairments, as well as poor safety awareness. Despite these documented needs and the occurrence of multiple falls, the care plan was not revised in a timely manner to address the specific risks and needs identified. Staff interviews indicated gaps in communication and understanding of care plan responsibilities, with several staff members unaware of the resident's fall history or the need for care plan updates following incidents.
Medication Error Rate Exceeds 5% in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6% error rate during a survey. This was based on two errors out of 29 opportunities involving two residents and two staff members. The first error involved LVN B, who did not administer Thiamine 100 mg to a resident because it was unavailable in the medication cart. The resident, who had chronic kidney disease, congestive heart failure, and hypertension, was later sent to the hospital for an increased ammonia level before the medication could be administered. The second error involved RN A, who failed to administer Metoprolol 50 mg to another resident. This resident had a history of pain in the right knee, an artificial right knee joint, atrial fibrillation, and hypertension. RN A did not administer the medication during the observed medication pass, despite the resident's blood pressure and heart rate being within the parameters for administration. The resident later confirmed that the medication, which she recognized by its pink color, was not given. Interviews with the staff revealed that LVN B acknowledged the unavailability of Thiamine at the time of administration, and RN A was unable to confirm the administration of Metoprolol, despite initially stating it was given. The resident's recollection and the absence of the medication in the cart supported the surveyor's findings of the medication error.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This deficiency was identified during a review of the controlled medication count sheets for Hall 100, where it was found that the facility staff did not follow their policy to perform shift counts/audits at shift change and complete the log. Specifically, there were six instances on the Controlled Drugs-Count Record where the required shift counts/audits were left blank, and these blanks were later filled in days after the fact by LVN D, who could not provide an explanation for this action. Interviews conducted during the investigation revealed that the Director of Nursing (DON) acknowledged that controlled medications should be counted by both the oncoming and outgoing nurses each shift. The DON also deemed the practice of filling in blanks on the count sheet as 'unacceptable.' Despite being presented with evidence of the filled-in blanks, LVN D was unable to explain why the boxes were initialed after the fact. The facility's policy on the management of controlled medications clearly states that controlled medications must be counted at every shift change by authorized staff, and both the outgoing and incoming staff must verify and sign the count sheet, which was not adhered to in this case.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 179 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rosenberg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosenberg Health & Rehabilitation Center | 2.2 mi | ★★★★★ | 5 | 1 |
| Paradigm At The Brazos | 4 mi | ★★★★★ | 0 | 0 |
| Oak Bend Medical Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Cambridge Health And Rehabilitation Center | 4.2 mi | ★★★★★ | 8 | 0 |
| Richmond Health Care Center | 4.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.