Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Kingwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents were exposed to harm due to inadequate supervision and environmental safety. One resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unnoticed and was later found by a bystander after experiencing falls. The resident's care plan did not address elopement risk, and staff were not consistently aware of or monitoring for such behaviors. Additionally, an unsecured oxygen tank was found in another resident's room, presenting an accident hazard.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions, as observed in the care planning documentation.
A resident was not provided with the necessary assistance to access vision and hearing services, resulting in unmet care needs in these areas.
Staff failed to properly secure and label medications on a medication cart, leaving a resident's medications unattended and the cart unlocked during administration. Multiple opened topical medications were found on the cart without dates or resident names, and staff confirmed there was no consistent policy for dating opened medications.
Staff did not immediately inform a resident, the resident's doctor, and a family member about incidents such as injury, decline, or room changes that affected the resident, as required by policy.
A nurse failed to fully administer prescribed doses of carvedilol, misoprostol, and famotidine via G-tube to a resident with multiple complex conditions, resulting in a medication error rate of 8%. The nurse did not properly rinse the medication cup, leaving residue and nearly discarding part of the dose before being corrected by a surveyor.
An LVN failed to disinfect a glucometer between uses on two residents with diabetes and other chronic conditions, using the same device without cleaning it and storing it improperly, contrary to facility infection control policy.
A resident with paraplegia and multiple wounds did not receive prescribed wound care, turning, or assistance with transfers, leading to wound deterioration, severe sepsis, and hospitalization. Staff interviews and observations revealed missed wound care, lack of accountability, and failure to follow care plans. Additionally, another resident was not protected from alleged staff abuse, with the accused staff member continuing to provide care after the allegation. These failures placed residents at risk for harm and were identified as Immediate Jeopardy situations.
A resident with Parkinson's disease, requiring significant assistance and with intact cognition, reported to the DON and administrator that an LVN physically and verbally abused him, including jabbing him with a needle and hitting him in the face. Despite these allegations, the facility did not notify the abuse coordinator, did not investigate, and allowed the LVN continued access to the resident. Both the DON and administrator failed to follow required reporting and investigation procedures, resulting in a lack of protection for the resident.
A resident with Parkinson's disease reported being stabbed with an insulin needle and scratched by an LVN, expressing fear and discomfort with the nurse's care. Despite these allegations, the facility did not promptly investigate, report, or remove the LVN from providing care, and the required notifications and assessments were not completed. The resident continued to receive care from the LVN after the report, and the incident was not immediately reported to the state or fully investigated as required by facility policy.
Three residents did not receive consistent wound care as ordered, including missed dressing changes, inadequate turning and repositioning, and failure to follow wound care specialist instructions. One resident with paraplegia and multiple wounds experienced deterioration leading to hospitalization for severe sepsis and surgical debridement. Staff interviews and observations confirmed lapses in daily wound care for two other residents, with soiled dressings left unchanged. Residents and families reported ongoing concerns about missed care and poor communication, and staff shortages contributed to the deficiencies.
A resident with severe cognitive and physical impairments, who required total assistance and a mechanical lift for transfers, was improperly transferred by a CNA using a gait belt as a one-person assist. This action, which was not in accordance with therapy assessments or the care plan, resulted in the resident being found alone with a head injury and hip fracture. The facility did not ensure adequate supervision or implement required safety interventions for this high-risk individual.
The facility failed to provide adequate pharmaceutical services, as LVNs did not ensure correct narcotic counts during shift changes and failed to document narcotic administration accurately for several residents. A resident was administered the wrong medication due to a failure to verify the correct prescription. These issues highlight discrepancies in narcotic counts and documentation, contrary to facility policy.
A resident with multiple medical conditions was unable to access the call light due to it being wrapped around the wall base, contrary to the care plan and facility policy. Staff interviews confirmed the importance of accessible call lights, and the administrator acknowledged the deficiency.
A facility failed to refer a resident with serious mental disorders for a Level II PASARR evaluation after a significant change in status. The resident, with diagnoses including delusional disorder and bipolar disorder, was not evaluated despite a decline in cognition and the presence of mental health issues. The MDS Coordinator did not realize the need for referral until prompted by a state surveyor, contrary to the facility's policy requiring appropriate screening for specialized services.
A resident with Type 2 Diabetes had a blood sugar level of 422, but the LVN failed to notify the NP or administer the ordered insulin. The resident's care plan required monitoring and communication with the NP for abnormal blood sugar levels, but these protocols were not followed, as confirmed by interviews with facility staff.
A facility failed to document a correct diagnosis for a resident prescribed Seroquel, an antipsychotic medication, for dementia, which was inappropriate. Despite recommendations from a consultant pharmacist to change the diagnosis to delusion disorder, the facility did not update the resident's records in a timely manner. This oversight resulted in the resident receiving unnecessary medication, as the facility did not adhere to its policy of monthly medication regimen reviews.
A facility experienced a medication error rate of 11%, involving two residents. One resident did not receive the full dose of Lacosamide until a state surveyor intervened, due to an LVN not wearing glasses. Another resident received Sucralfate late and missed a dose of Lexapro, as the MA's shift timing and medication unavailability contributed to the errors. The facility's policy requires medications to be administered within one hour of their scheduled time.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in their oxygen therapy orders. One resident was observed without oxygen despite having a continuous order, while another was on oxygen without a documented order. The facility's policies on documentation were not followed, resulting in incomplete records and potential risks for the residents.
Failure to Prevent Elopement and Address Accident Hazards
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with severe cognitive impairment, Alzheimer's disease, and a history of exit-seeking behaviors was able to leave the facility without staff knowledge. The resident was last seen in the lobby in the early evening and was later found by a bystander walking unsteadily on a nearby road, having experienced falls and an incontinent episode. The facility was unaware of the resident's whereabouts for several hours until notified by an external party. Prior to the incident, the resident's care plan did not include interventions for elopement risk, despite previous assessments indicating a history of elopement or exit-seeking behaviors. Staff interviews revealed inconsistent awareness of the resident's risk, and the front door was not secured at the time, allowing the resident to exit undetected. Additionally, the facility was found to have an unsecured, empty oxygen tank on the floor in another resident's room, presenting a potential accident hazard. This situation exposed residents to possible harm, injury, or death due to inadequate monitoring and environmental safety measures. The facility's policies required identification and mitigation of hazards, as well as routine checks and documentation, but these were not effectively implemented in these cases. Interviews with staff indicated that while some were aware of general elopement protocols, there was a lack of specific interventions and communication regarding residents at risk for elopement. Documentation and care planning did not reflect the resident's exit-seeking behaviors, and staff did not consistently monitor or report such behaviors. The failure to secure the environment and provide adequate supervision directly contributed to the resident's elopement and the presence of accident hazards in the facility.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to necessary vision and hearing services. The facility failed to ensure that the resident received support to obtain these services, as required. This lack of assistance resulted in the resident not having access to appropriate vision and hearing care.
Failure to Secure, Label, and Date Medications on Medication Cart
Penalty
Summary
Facility staff failed to properly store, label, and secure medications and biologicals on at least one medication cart. During a medication pass, a nurse left a resident's medications unattended on top of an unlocked medication cart while leaving the room to obtain manual blood pressure cuffs. The medication cart remained unlocked and unattended during the process, and the nurse also left the resident's room door open while administering medications, without pulling the privacy curtain. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had multiple complex medical diagnoses, including chronic atrial fibrillation, stroke, and diabetes. Additionally, an inspection of the medication cart revealed several topical medications and creams that were opened but not dated or labeled with a resident's name. Staff interviews confirmed that there was no consistent practice for dating opened medications, and the facility lacked a policy on this matter. The Director of Nursing and Consultant Pharmacist acknowledged that the pharmacist typically placed the opened date on ointments, but this was not consistently done, and staff were unsure of the effectiveness of undated medications.
Failure to Promptly 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 report specifically notes that required notifications were not made promptly when events impacting the resident occurred, as mandated by regulations.
Medication Error Rate Exceeds 5% Due to Incomplete Administration via G-Tube
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with 3 errors out of 37 opportunities, resulting in an 8 percent error rate. During a medication pass, LVN J did not administer the full dose of carvedilol, misoprostol, and famotidine as ordered by the physician to a resident with multiple complex medical conditions, including chronic atrial fibrillation, coronary artery disease, stroke, diabetes, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living and received medications via gastrostomy tube. On the observed medication pass, LVN J prepared the medications by crushing them and placing them in a medication cup, but did not stir or rinse the cup, leaving a significant amount of residue. The nurse was about to discard the cup with the remaining medication when a surveyor intervened and pointed out the residual. LVN J acknowledged the error and subsequently administered the remaining medication after adding water. LVN J stated she had received gastrostomy tube training but was nervous during the process. The facility's policy required medications to be administered safely, timely, and as prescribed.
Failure to Disinfect Glucometer Between Residents
Penalty
Summary
A deficiency occurred when an LVN failed to follow infection prevention and control protocols during blood glucose monitoring for two residents. The LVN used the same accu-check machine to check the blood glucose levels of both residents without wiping or sanitizing the device between uses. After checking the first resident, the LVN placed the machine inside the medication cart, then proceeded to use it on the second resident, and subsequently stored it in his uniform pocket and then in the medication cart, again without cleaning it. The LVN stated that in his previous employment, cleaning the device between residents was only done for those on contact isolation, and he had not received orientation at the current facility. He acknowledged awareness that wiping the device was intended to prevent infection. The two residents involved had significant medical histories, including diabetes, hypertension, chronic kidney disease, dementia, and other conditions that could increase their vulnerability to infection. The facility's infection prevention and control policy required all reusable equipment to be cleaned and disinfected according to established procedures. However, the LVN did not adhere to these protocols, as observed during the medication pass, and this lapse was confirmed through interviews and record review.
Failure to Prevent Neglect and Abuse, Resulting in Wound Deterioration and Resident Distress
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by the lack of implementation of required interventions and inadequate wound care management. One resident, a cognitively intact female with paraplegia and multiple complex medical conditions including stage 3 and 4 pressure ulcers, osteomyelitis, and a suprapubic catheter, did not receive prescribed wound care treatments, turning and repositioning, or assistance with transfers to a chair as ordered. Documentation and interviews revealed that wound dressings were not changed as required, the resident was not turned or repositioned according to care plans, and she was left in soiled conditions for extended periods. The resident and her family repeatedly reported these issues to facility leadership, but corrective actions were not taken, resulting in wound deterioration, severe sepsis, and hospitalization for surgical wound debridement. Staff interviews indicated confusion and lack of accountability regarding wound care responsibilities, with several nurses and CNAs stating that wound care was often missed or improperly delegated, especially when the designated wound care nurse was unavailable. Observations confirmed that wound dressings were not changed daily as ordered, and some residents were found with dressings that had not been replaced for multiple days. The facility's own wound care consultant noted that dressings were frequently saturated and that the resident was not being mobilized as required, further contributing to the risk of infection and poor wound healing. Additionally, the facility failed to protect another resident from alleged verbal and physical abuse by a staff member, allowing the accused staff to continue providing care to the resident after the allegation was made. The resident expressed fear of the staff member, yet no immediate action was taken to prevent further contact. These failures were identified as Immediate Jeopardy situations by surveyors, as they placed residents at risk for physical harm, mental anguish, and neglect. The facility's policies required prompt identification and intervention in cases of abuse and neglect, but these were not followed, resulting in significant deficiencies in resident care.
Failure to Implement Abuse Policy Following Resident Allegation
Penalty
Summary
The facility failed to implement its abuse policy when a resident with Parkinson's disease, who required significant assistance with daily activities and had intact cognition, made allegations of physical and verbal abuse by a licensed vocational nurse (LVN). The resident reported to both the DON and the administrator that the LVN jabbed him with a needle, causing pain, and hit him in the face while administering medication. The resident also expressed fear of retaliation and discomfort with the LVN continuing to provide care. Despite these reports, the facility did not notify the abuse coordinator, did not initiate an investigation, and allowed the alleged abuser continued access to the resident after the allegations were made. Interviews and record reviews revealed that the DON was informed of the resident's complaints, including pain from an injection and fear of the LVN, but did not complete a thorough assessment, notify the abuse coordinator, or report the incident as required by policy. The administrator, who also served as the abuse coordinator, was made aware of the resident's allegations but did not file a report with the state. Both the DON and administrator acknowledged in interviews that proper reporting and investigation procedures were not followed. The resident was subsequently moved to a different hallway, which he perceived as retaliatory, and the LVN continued to have access to him during this period. The facility's failure to follow its abuse, neglect, and exploitation policy resulted in the lack of timely reporting, investigation, and protection for the resident. The events were substantiated by audio recordings, interviews with the resident, staff, and therapy personnel, and review of facility documentation. These failures placed residents at risk for physical harm and mental anguish, as the required protocols to ensure resident safety and address allegations of abuse were not implemented.
Failure to Investigate, Report, and Protect After Abuse Allegation
Penalty
Summary
The facility failed to immediately investigate, report, and protect a resident following allegations of abuse and neglect by a licensed vocational nurse (LVN). The resident, a 51-year-old male with Parkinson's disease and other medical conditions, reported being stabbed in the arm with an insulin needle and scratched on the nose by the LVN. He also described being hit in the face when receiving medication and expressed fear and discomfort regarding the LVN's care. Despite these reports, the facility did not promptly initiate an investigation or remove the LVN from providing care to the resident. Interviews and record reviews revealed that the resident communicated his concerns to both the DON and the administrator, including his fear of retaliation and his desire for the issue to be handled discreetly. The DON acknowledged being informed of the resident's pain and discomfort after an injection but did not conduct a thorough assessment, notify the abuse coordinator, or report the incident as required. The administrator, who also served as the abuse coordinator, was not immediately informed of the allegations and did not file a report with the state upon learning of the situation. The LVN continued to provide care to the resident after the initial report, and the resident was later moved to a different hallway, which he perceived as retaliatory. The facility's own policy required all reports of abuse, neglect, or exploitation to be reported to appropriate agencies and thoroughly investigated, but this was not followed in this case. The failures in immediate investigation, reporting, and protection placed the resident at risk for physical harm and mental anguish. The deficiency was identified as Immediate Jeopardy, and the facility was found out of compliance due to the lack of effective corrective systems at the time of the incident.
Failure to Provide Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents reviewed for wound treatment and services. Specifically, one resident with paraplegia and multiple complex wounds did not receive wound care interventions as ordered, including scheduled bandage changes, regular turning and repositioning, and being placed in a chair twice daily. Documentation and interviews revealed that wound care was not consistently provided, with missed dressing changes and inadequate implementation of physician and wound care specialist orders. As a result, the resident's wounds deteriorated, leading to hospitalization for severe sepsis and surgical wound debridement. Record reviews and staff interviews confirmed that wound care was not provided daily as ordered for two additional residents, with at least one instance where wound dressings were not changed for an entire day. Observations showed soiled and saturated dressings, and staff acknowledged that either the wound care nurse or charge nurses were responsible for providing wound care in the absence of the designated wound care nurse. However, this responsibility was not consistently fulfilled, and dressings were left unchanged, increasing the risk of infection and delayed healing. Interviews with residents, family members, and staff highlighted ongoing concerns about inadequate care, poor communication, and lack of responsiveness to resident needs. One resident and her family reported repeated complaints to facility leadership about missed turning, infrequent dressing changes, and being left in soiled conditions, with little to no resolution. Staff shortages, lack of continuity in wound care nursing, and inconsistent adherence to care plans and physician orders contributed to the deficiencies observed. These failures placed residents at risk of physical harm, including infection and wound deterioration.
Failure to Provide Safe Transfer and Supervision Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents. The resident involved was a bedbound female with severe cognitive impairment, contractures, and multiple comorbidities, including dementia, COPD, and congestive heart failure. She was totally dependent on staff for all activities of daily living and required substantial to total assistance for transfers, with therapy assessments specifying the use of a Hoyer lift for all transfers due to her inability to move or assist herself. Despite these requirements, the resident was transferred by a CNA using a gait belt as a one-person assist, contrary to therapy instructions and the care plan, which specified two-person assistance and the use of a mechanical lift. Following this improper transfer, the resident was found alone in her room with a hematoma on her forehead and a fractured hip. Multiple staff interviews and record reviews confirmed that the resident was unable to move independently and that the transfer method used was not appropriate for her condition. The care plan and therapy notes clearly indicated the need for mechanical lift assistance, and staff were aware of her high risk for falls and injury due to her frailty and cognitive impairment. The incident was not immediately reported, and there was a lack of prompt recognition and response to the resident's injury. Documentation and interviews revealed inconsistencies in staff accounts regarding the events leading up to the injury, and the facility failed to ensure that precautionary interventions and supervision were in place for this known high-risk resident. The failure to follow established care plans and therapy recommendations directly led to the resident sustaining significant injuries while left unsupervised.
Pharmaceutical Service Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by several discrepancies in the administration and documentation of narcotic medications. Licensed Vocational Nurses (LVNs) J and C did not ensure the narcotic count was correct during shift changes for four residents. Additionally, LVN J failed to document the administration of narcotic medications accurately for these residents, which included administering the wrong medication to one resident. Resident #68, a male with moderate cognitive impairment and multiple diagnoses including chronic pain, was prescribed Tramadol 37.5 mg - Acetaminophen 325 mg. However, he was administered Tramadol 50 mg instead, due to a failure to verify the correct medication. This error was compounded by the lack of documentation on the narcotic log, leading to discrepancies in the narcotic count. Similar issues were observed with Resident #18, who did not have the administration of Acetaminophen-Codeine #3 properly documented, and Resident #25, whose administration of Norco was not recorded on the narcotic log. Resident #3, who has moderate cognitive impairment and a history of pain, was also affected by these documentation failures. The facility's policy requires that controlled substances be accurately documented and counted at the end of each shift, but these procedures were not followed. Interviews with the staff revealed a lack of attention to detail and hurried practices during shift changes, contributing to the inaccuracies in narcotic counts and documentation.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #79, had reasonable access to a call light system, which is crucial for requesting staff assistance. During an observation, it was noted that Resident #79's call light cord was wrapped around the call light base on the wall, making it inaccessible to him. This deficiency was identified through interviews, observations, and record reviews. Resident #79, a man with multiple medical conditions including metabolic encephalopathy, pulmonary embolism, type 2 diabetes, chronic kidney disease, dementia, and other disorders, was unable to reach the call light due to its improper placement. His care plan specifically included an intervention to place the call light within his reach, which was not adhered to. Interviews with staff members, including a CNA and an LVN, confirmed that the call light was not within reach of Resident #79, and they acknowledged the importance of having the call light accessible to residents. The facility's administrator also stated that the call lights should be placed where residents can use them and that the current placement did not meet her expectations. The facility's policy on answering call lights emphasized that the call light should be within easy reach of residents, which was not the case for Resident #79.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorders for a Level II PASARR evaluation upon a significant change in status assessment. This deficiency was identified for one of the eighteen residents reviewed for PASARR evaluations. The resident in question, a female with multiple diagnoses including delusional disorder, mood disorder, generalized anxiety disorder, psychosis, and bipolar disorder, was not referred to the appropriate state-designated authority for further evaluation. Upon admission, the resident's MDS assessment indicated moderately impaired cognition, and she was not evaluated by PASARR, with no serious mental illness noted. However, subsequent assessments showed a decline in cognition and the presence of serious mental health diagnoses, including anxiety, depression, and a psychotic disorder. Despite these findings, the resident was not referred for a Level II PASARR evaluation, which could have identified the need for specialized mental health services. The MDS Coordinator admitted to not realizing the need for a PASARR referral until prompted by a state surveyor. The facility's policy requires that all new admissions be appropriately screened to determine the need for specialized services, but this was not adhered to in this case. The oversight in the PASARR process could potentially lead to residents not receiving necessary mental health services, as highlighted by the coordinator's acknowledgment of the risk of residents falling through the cracks.
Failure to Administer Insulin and Notify NP for High Blood Sugar
Penalty
Summary
The facility failed to ensure that Resident #35 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. On 5/13/24, LVN M recorded a blood sugar level of 422 for Resident #35 but did not document notifying NP B or administering the 10 units of insulin that were ordered. This oversight was identified during a review of Resident #35's medical records, which showed no documentation of insulin administration or notification to the nurse practitioner. Resident #35, a male with a history of Type 2 Diabetes, was at risk for hyperglycemia due to his condition. His care plan included monitoring blood sugar levels and notifying the nurse practitioner if levels were outside the specified range. Despite these instructions, there was no record of communication with NP B regarding the elevated blood sugar level on 5/13/24, nor was there any documentation of insulin being administered to address the high blood sugar. Interviews with NP B, RN P, and the ADON confirmed that the facility's protocol required staff to notify the nurse practitioner of any blood sugar readings outside the specified range and to document any subsequent orders and actions taken. However, in this instance, LVN M did not follow these procedures, resulting in a lack of appropriate response to Resident #35's high blood sugar level.
Failure to Document Correct Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a psychotropic drug prescribed to a resident was free from unnecessary use. Specifically, the facility did not document a correct diagnosis, nor did it monitor the effectiveness and side effects of Seroquel, an antipsychotic medication, prescribed to a resident. The resident, a man with dementia, affective disorder, and anxiety disorder, was administered Seroquel for dementia, which was not an appropriate diagnosis for the medication. The resident's care plan included monitoring for adverse medication reactions and signs of depression, but the facility did not update the underlying diagnosis for the Seroquel prescription despite recommendations from the consultant pharmacist. The pharmacist had advised that the medication should be prescribed for an appropriate psychiatric diagnosis, such as delusion disorder, rather than dementia. The facility's Assistant Director of Nursing (ADON) acknowledged that the diagnosis should have been changed in March when the recommendation was made and agreed upon by the physician. The facility's Medication Regimen Reviews policy required the consultant pharmacist to review each resident's medication regimen monthly to identify errors, including documentation errors. However, the facility did not act on the pharmacist's recommendation in a timely manner, resulting in the resident receiving Seroquel under an incorrect diagnosis for several months. This oversight placed the resident at risk of receiving unnecessary medications.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11% due to three errors out of 27 opportunities. This involved two residents, one of whom did not receive the full dose of Lacosamide, a medication for seizure control, until a state surveyor intervened. The Licensed Vocational Nurse (LVN) responsible for administering the medication admitted to not wearing glasses, which led to the oversight of leaving 2.5 to 5 mL of the medication in the cup. The Assistant Director of Nursing (ADON) acknowledged that all medication should be administered as ordered, and the facility conducts competency checks for feeding tube medication administration. Another resident was affected by medication administration errors when a Medication Aide (MA) administered Sucralfate later than scheduled and failed to administer Lexapro as ordered. The MA's shift started at 8:00 a.m., and she was responsible for two halls of residents, which contributed to the delay. The Pyxis machine did not have the Lexapro, and the pharmacy was notified to send it immediately. The ADON noted that medications should be reordered seven days in advance to ensure availability and acknowledged the importance of administering Sucralfate before meals. The facility's policy on administering medications, dated December 2012, states that medications should be administered safely, timely, and as prescribed, within one hour of their scheduled time unless specified otherwise. The Administrator expressed the expectation that medications be administered correctly and according to the physician's order. The report highlights the facility's failure to adhere to these policies, resulting in a medication error rate exceeding the acceptable threshold.
Inaccurate Medical Records and Oxygen Therapy Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to discrepancies in their oxygen therapy orders. Resident #48, a female with multiple diagnoses including COPD and respiratory failure, was observed without oxygen despite having a continuous oxygen order in her records. Interviews revealed that there was a discussion about discontinuing her oxygen, but no order was placed to reflect this change. The nursing staff continued to sign off on the administration of oxygen, indicating a lack of communication and oversight in updating her medical records. Resident #63, a male with conditions such as heart failure and dementia, was observed using oxygen continuously, yet there was no physician order documented for this treatment. Despite being on oxygen, his medical records did not reflect this, and the nursing staff failed to identify the absence of an order. This oversight could lead to the resident receiving unnecessary oxygen, as there was no documented need or physician directive for its use. The facility's policies on charting and documentation, as well as medication and treatment orders, were not adhered to, resulting in incomplete and inaccurate medical records. The Assistant Director of Nursing acknowledged the responsibility for overseeing these errors, highlighting a systemic issue in ensuring that medical records are updated and accurate. The lack of proper documentation and communication among staff members contributed to the deficiencies observed in the care of these residents.
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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 Kingwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights On Valley Ranch | 3.8 mi | ★★★★★ | 0 | 0 |
| Crimson Heights Health & Wellness | 4.3 mi | ★★★★★ | 15 | 0 |
| Deerbrook Skilled Nursing And Rehab Center | 4.4 mi | ★★★★★ | 14 | 3 |
| Park Manor Of Humble | 4.5 mi | ★★★★★ | 9 | 0 |
| Focused Care At Humble | 4.7 mi | ★★★★★ | 1 | 0 |
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