Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Mont Belvieu Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Failure to provide required RN coverage and full-time DON oversight. The facility did not have an RN on duty for 8 consecutive hours on multiple days and did not have a full-time RN DON after the prior DON left. Interviews showed the Administrator was responsible for RN coverage and hiring a DON, while the Director of Clinical Operations and ADON were only available part-time or by phone. Facility policy required Nursing Services to be under the direct supervision of an RN and the DON to be an RN employed full-time.
Kitchen Stove Burners Not Operating Safely: The Dietary Manager found one burner on the stove was nonfunctional and disconnected, and several other burners would not light with the pilot lights, requiring use of a long stem lighter. The Administrator was told the burners were not lighting properly, and the Maintenance Supervisor said he had not been notified of the issue until after surveyor intervention. The facility policy required all stove and cooktop equipment to be maintained in safe, operable condition and for malfunctions to be reported immediately.
MDS assessments failed to accurately code a resident’s dental status. The resident had missing, broken, and loose teeth and said she had not seen a dentist since admission, but her admission and quarterly MDS did not reflect the dental concerns. An LVN later checked the resident after surveyor intervention and said she needed to be on the dental referral list, while the MDS nurse and DON leadership acknowledged the issue had been missed.
A resident with atrial fibrillation was prescribed apixaban, but the facility did not add or document the required side effect monitoring for the anticoagulant. The care plan and consultant pharmacist review both referenced anticoagulant monitoring, yet the electronic record showed no monitoring was completed. RN, ADON, Director of Clinical Operations, and the Administrator all acknowledged the oversight and stated the resident should have been monitored for bleeding and other side effects.
A resident with intact cognition, diabetes, CHF, and a mechanically altered diet was not assisted with routine or emergency dental care despite reporting that she had not seen a dentist since admission and showing broken teeth at the gum line, loose lower teeth, and missing upper teeth. Staff said dental concerns and appointments were handled by the DON and SW but had been overlooked, and the resident was not on the list of residents who had seen the dentist.
A resident with dementia, severe cognitive impairment, a history of falls, and dependence on staff for transfers was manually transferred from a wheelchair to bed by a CNA without use of a gait belt, despite the resident’s care plan and facility practice requiring such assistance for manual transfers. During the observed transfer, the CNA used a bear hug technique, lifting around the resident’s chest while the resident, who was very unsteady and shaky, held onto the bed rail. Therapy staff and multiple CNAs and LVNs reported that gait belts were required for residents needing manual transfers, and the CNA involved acknowledged she had been trained to use a gait belt and should have used it instead of the bear hug method, which conflicted with the facility’s safe lifting policy.
A resident with multiple chronic conditions was receiving clysis after an unsuccessful IV attempt when the clysis line became dislodged and the site was cleansed, with no order to re-insert. The RN who had used the subcutaneous needle left the used sharps and tubing hanging on an IV pole in the resident’s room instead of immediately discarding them into a sharps container as required by facility policy. When the resident was later found unresponsive and CPR was in progress, an EMS provider grabbed the IV pole to remove a saline bag and sustained a needlestick from the sharps still attached to the tubing. Another RN then removed the bag and sharps and placed them in regular trash at the nurse station before later retrieving them, actions that staff and leadership acknowledged were inconsistent with the facility’s sharps disposal policy and infection control requirements.
A resident with multiple complex medical conditions experienced a significant change in status, including shortness of breath and a new pleural effusion requiring antibiotics. Facility staff did not notify the resident's representative of the change, the x-ray, or the results, and there was no documentation of such notification, contrary to facility policy and expectations.
The facility did not report allegations of misappropriation of property and verbal abuse involving two residents to the State Survey Agency within the required timeframes. In both cases, the administrator conducted internal investigations but did not make the mandated external reports because the allegations could not be substantiated internally, despite regulatory requirements for immediate reporting.
The facility failed to store and distribute food according to professional standards, as observed during a kitchen inspection. Issues included improperly labeled and dated foods, expired items not discarded, and improper storage practices. The Dietary Manager confirmed these deficiencies, acknowledging the risk of cross-contamination and the use of spoiled foods, which could pose a health risk to residents.
A resident receiving enteral feeding due to dysphagia and aphasia was improperly administered medications through a G-tube by an LVN, who crushed multiple medications together and used a syringe plunger instead of gravity flow, contrary to facility policy. This led to the G-tube clogging and potential risks to the resident's health. The DON confirmed the facility's policy requires separate administration of medications by gravity flow.
A resident with atherosclerotic heart disease requiring oxygen therapy was found to have an empty humidifier bottle and a dirty oxygen concentrator filter. Staff interviews revealed a lack of responsibility and oversight in maintaining the equipment, leading to potential inadequate oxygen support. Facility policies were not followed, resulting in the oversight.
A LTC facility failed to ensure proper medication administration for two residents. One resident was left with a Senna tablet at the bedside, contrary to policy, and did not take it due to loose stools. Another resident did not receive midodrine as prescribed when her blood pressure was low, despite carvedilol being held. These actions were against facility policy, which requires medications to be administered safely and as prescribed.
A resident with diabetes did not receive the prescribed controlled carbohydrate (CC) diet during breakfast meals, receiving regular syrup and jelly instead of diet versions. Despite the dietary card indicating the need for diet condiments, the facility's staff, including an LVN, DON, DM, and dietician, failed to ensure compliance with the resident's dietary plan.
Two residents were involuntarily secluded when a CNA placed gloves in their door frame to prevent one from wandering. One resident, who was cognitively intact, was unable to leave the room for her morning coffee, while the other, who was severely cognitively impaired, remained unaware of the incident. The facility's policy against involuntary seclusion was violated.
A facility failed to report an abuse allegation involving involuntary seclusion within the required timeframe. Two residents were secluded in their room by a CNA using gloves to block the door. Resident #1, cognitively intact, and Resident #2, severely cognitively impaired, were involved. The facility's policy requires immediate reporting of such incidents, but the report was delayed, indicating a deficiency in their reporting procedures.
A resident with acute respiratory failure and other medical conditions was sent to the hospital without proper documentation of their change in condition, physician notification, and transport. The LVN involved acknowledged forgetting to document these events due to a hectic situation. The facility's policy requires such documentation to ensure timely care.
Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to use the services of an RN for at least 8 consecutive hours a day, 7 days a week, and failed to designate an RN as the DON on a full-time basis. Review of RN payroll hours for the period from 02/17/26 through 03/18/26 showed no RN services on 02/26/26, 03/11/26, 03/12/26, and 03/16/26. The previous DON’s last day of employment was 02/17/26, and the facility had not hired a full-time DON during the period reviewed. During interviews, the HR Director stated the Administrator was responsible for ensuring daily RN coverage and hiring a DON. The Administrator acknowledged the facility did not have RN coverage or an acting DON and said the facility had been actively advertising for the DON position and interviewing candidates, but no one had been hired. The Administrator also stated the Director of Clinical Operations was available on-call and visited the facility 2 to 3 days a week, but was not working full-time in the facility. Staff interviews confirmed the absence of a full-time DON and the intermittent presence of RN oversight. An LVN stated the lack of an RN and DON could create challenges when a more in-depth assessment was needed, although staff could seek guidance from the ADON, physicians, nurse practitioner, pharmacy, or dietitian. The ADON stated she was an LVN, the facility had been without a full-time DON since 02/17/26, and she was available by telephone and in the building 2 to 3 days a week. The Director of Clinical Operations stated she was not the full-time DON and only visited the facility 2 to 3 times a week, while the facility policy required the Nursing Services Department to be under the direct supervision of an RN and the DON to be a registered nurse employed full-time 40 hours per week.
Kitchen Stove Burners Not Operating Safely
Penalty
Summary
The facility failed to maintain the kitchen gas stove in safe operating condition. During an observation and interview on 03/16/2026 at 8:39 a.m., the Dietary Manager said the front right burner was not functional, the control knob had been removed, and the gas line to that burner was disconnected. He also turned on the other five burners and found that three back burners did not light with the pilot lights, so he used a long stem lighter to ignite them. He stated there was no smell of escaping gas and said the stove needed to work properly so there would be no delays with meals. Later observations showed the stove continued to have burner ignition problems. On 03/17/2026 at 11:30 a.m., the Dietary Manager turned on five burners and one back middle burner did not light with the pilot light, so he immediately turned it off and said he would get maintenance to adjust the pilot light. The Administrator stated he had been informed that three burners did not light with the pilot light and that the Dietary Manager used the long stem lighter to light them. The Maintenance Supervisor later said he had not been told the burners were not working with the pilot light until after surveyor intervention and stated his expectation was for kitchen staff to notify him when equipment was not working properly. The facility policy stated maintenance service shall be provided to all equipment, including stoves, ovens, and cooktops, and that kitchen equipment malfunction or repair needs are to be reported immediately to the Maintenance Director.
MDS assessments failed to reflect resident’s dental status
Penalty
Summary
The facility failed to ensure Resident #14’s MDS assessments accurately reflected her dental status. Her admission MDS dated 05/27/2025 and quarterly MDS dated 01/28/2026 did not indicate obvious or likely cavities or broken natural teeth, inflamed or bleeding gums or loose natural teeth, or mouth or facial pain/discomfort with chewing, even though the resident had missing teeth and dental concerns. The resident’s record showed diagnoses including congestive heart failure, skin cancer, and diabetes, and she had a mechanical soft-ground diet order in place. During observation and interview on 03/16/2026, Resident #14 stated she had not seen a dentist since coming to the facility and wanted to. She pointed out two broken teeth at the bottom jaw, four loose teeth on the bottom jaw, and missing teeth on the top jaw, and said she had dental issues when admitted. On 03/18/2026, LVN C checked the resident’s dental concerns after surveyor intervention and stated the resident needed to be on the dental referral list and that the issue had been missed. The MDS nurse stated the resident should have been triggered for dental issues on the MDS assessments, and the Director of Clinical Operations said the dental concerns had been overlooked and should have been coded on the MDS and addressed.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that Resident #55’s drug regimen was free from unnecessary medications by not monitoring her apixaban for side effects. Resident #55 was an older female resident with diagnoses including atrial fibrillation and moderately impaired cognition, with a BIMS score of 10. She was prescribed apixaban 2.5 mg twice daily for atrial fibrillation, and the medication remained active on her orders and MAR during the review period. Record review showed that the physician order for apixaban did not include monitoring for side effects, and the electronic record from the start of the medication through the survey date did not show monitoring for side effects of the anticoagulant. Her care plan identified anticoagulant therapy and included interventions to monitor and document side effects and effectiveness every shift, and the consultant pharmacist’s medication regimen review recommended adding anticoagulant monitoring. Despite these references, the monitoring was not entered into the computer system and was overlooked. During interviews, RN A stated the resident should have been monitored for side effects but was not, and said the charge nurse entering the order was responsible for adding the monitoring, with the ADON as backup. The ADON stated the monitoring should have been added and acknowledged it was overlooked, noting the resident had gone to the hospital and the monitoring may not have been added back on return. The Director of Clinical Operations and the Administrator both stated the order and pharmacy recommendation were overlooked, and the Administrator said the expectation was that physician orders be followed, including monitoring and follow-up as appropriate.
Failure to Arrange Dental Care for Resident With Broken and Loose Teeth
Penalty
Summary
The facility failed to assist one resident with obtaining routine and 24-hour emergency dental care when she had dental concerns involving missing, broken, and loose teeth. Resident #14 was admitted with diagnoses including congestive heart failure, skin cancer, and diabetes, and her records showed intact cognitive ability on MDS assessments. Her care plan reflected that she required extensive assistance with oral care and supervision with eating, and she was on a mechanically altered diet. During observation and interview, the resident stated she had not seen a dentist since admission and wanted to. She pointed out two broken teeth at the gum line on her lower jaw, four loose and crooked lower teeth, and missing teeth on her upper jaw. Facility staff stated that the DON and social worker were responsible for dental concerns and appointments, but it had been overlooked, and the resident had not been on the list of residents who had seen the dentist. The facility’s dental services policy stated that routine and emergency dental services are available to meet residents’ oral health needs in accordance with assessment.
Failure to Use Gait Belt During Manual Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistance devices during a manual transfer for one resident. The resident was an elderly female with dementia, severe cognitive impairment, short- and long-term memory problems, dysphagia, a history of falls (including two falls without injury and one with minor injury), anxiety disorder, and depression. Her MDS and care plan documented that she was dependent on staff for chair-to-bed transfers and most ADLs, and that she required total assistance by one staff member for transfers and other self-care tasks. On the observed date and time, a CNA assisted the resident from her wheelchair to her bed without using a gait belt. The CNA placed an arm around the resident’s chest area, pulled her to a standing position, pivoted her toward the bed, lowered her onto the bed, removed her shoes, and assisted her into a lying position. During this transfer, the resident was noted to be very unsteady and shaky, and she held onto the bed side rail while being assisted. No gait belt was applied at any point during the transfer, despite the resident’s documented dependence and history of falls. Interviews with therapy and nursing staff established that facility practice and training required use of a gait belt for residents needing one- or two-person manual transfers. The COTA stated that the resident required assistance of one staff for transfers and that staff should use a gait belt for her, and further stated that lifting under the arms or around the chest (bear hug technique) was not acceptable. Multiple CNAs and LVNs confirmed they were expected to use gait belts for manual transfers. The CNA who performed the transfer acknowledged she had been trained to use a gait belt, recognized she should have used one during the observed transfer, and admitted she instead used a bear hug technique. The facility’s written “Safe Lifting and Movement of Residents” policy required use of appropriate techniques and devices, and staff training in manual devices such as gait belts, confirming that the observed transfer did not follow established procedures.
Improper Sharps Disposal Leading to Needlestick Injury
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of contaminated sharps in accordance with its infection prevention and control program and Sharps Disposal policy. A male resident with multiple medical conditions, including encephalopathy, anemia, diabetes, depression, anxiety, heart disease, kidney disease, and liver transplant status, had an order for IV fluids that was changed to clysis after an unsuccessful IV attempt. A clysis line was inserted into the resident’s left upper arm and later became dislodged, with clear fluid leaking from the site. The site was cleansed and the MD was notified, and there was no order to re-insert the clysis. After the clysis was dislodged, RN A reported that she hung the tubing and used sharps high on the IV pole in the resident’s room with the intention of returning to dispose of them properly, but she became busy with other residents and forgot. The used sharps remained attached to the IV pole instead of being immediately discarded into a sharps container as required by the facility’s Sharps Disposal policy. The resident did not have a roommate, but the used sharps were left in the room accessible to others. The facility’s policy stated that whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers that are closable, puncture resistant, leakproof, and properly labeled or color-coded. When the resident was later found unresponsive, CPR was initiated and EMS arrived and took over. EMS B entered the room to assist with CPR and, while removing a bag of saline from the IV pole, was stuck by the subcutaneous sharps that were still attached to the tubing and hanging from the pole. EMS B reported that she did not see the sharps before being stuck. RN D then removed the bag of saline and used sharps from the IV pole and initially placed them in a garbage bin at the nurse station instead of a sharps container. EMS B later asked to see the bag, and RN D retrieved it and the used sharps from the trash. Interviews with RN A, RN D, the ADON, and the Administrator confirmed that the used sharps should have been immediately disposed of in a sharps container and not left on the IV pole or placed in regular trash, and that this incorrect handling of sharps was contrary to the facility’s policy and created a risk of exposure to communicable diseases and infections for residents and staff.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative when there was a significant change in the resident's physical condition and a need to alter treatment. The resident, an elderly male with multiple complex diagnoses including acute kidney failure, muscle weakness, dysphagia, thrombocytopenia, gastrostomy status, sepsis, oral cavity carcinoma, diabetes type 2, atrial flutter, and deep vein thrombosis, experienced a change in condition characterized by shortness of breath and diarrhea. Orders were given for bowel rest, to hold tube feeding, obtain labs, provide nebulizer treatments as needed, and perform a chest x-ray. The chest x-ray revealed a small pleural effusion, and the physician ordered a course of antibiotics. There was no documentation that the resident's responsible party was notified of these changes, the x-ray, or the results. Interviews with the Director of Nursing (DON) and the Administrator confirmed that it was the facility's expectation and policy for nursing staff to notify the resident's representative of any change in condition, test orders, results, and new medication orders, and to document this notification in the electronic record. The facility's policies also required prompt notification of the resident's representative within 24 hours of a significant change in condition. Family members confirmed that they were not notified of the resident's change in status, x-ray, or results. The deficiency was identified through record review and interviews, with no evidence of notification to the responsible party documented.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property as required by regulations. For one resident, a family member reported that the resident's wallet containing $375.35 was missing from a dresser drawer. The incident was reported to the facility administrator, who conducted an internal investigation by interviewing the resident, her family, and staff, and searching the resident's room. However, there was no evidence that the allegation of misappropriation was reported to the State Survey Agency within the required 24-hour timeframe. In a separate incident, another resident's friend reported to the DON that a staff member allegedly called the resident a derogatory name, which constitutes verbal abuse. The administrator was notified, and both the staff member and the resident were interviewed. The staff member denied the allegation, and the resident expressed satisfaction with the outcome of the internal inquiry. Despite this, there was no indication that the allegation of verbal abuse was reported to the State Survey Agency within the required two-hour timeframe. Interviews with facility leadership confirmed that the administrator, who also served as the abuse coordinator, was aware of the reporting requirements but chose not to report the allegations externally because he could not substantiate them through internal investigation. The DON confirmed that all allegations of abuse are reportable within two hours, but the required external notifications were not made in these cases.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. Several issues were identified, including improperly labeled and dated stored foods, expired foods not being discarded, and improper storage practices. Specifically, a gallon bag of sliced American cheese was found without a date opened and exposed to air, and a tray of milk cups was not labeled or dated. Additionally, items in the dry pantry, such as a bottle of vanilla-hazelnut syrup and raspberry dessert topping, were past their best-by dates, and a bowl was improperly used as a scoop in a brown sugar container. The Dietary Manager acknowledged these deficiencies, stating that all items should be labeled with the date received and the date opened to prevent cross-contamination and the use of spoiled foods. The facility's policy requires that dry foods stored in bins be labeled and dated, and all refrigerated or frozen foods be covered, labeled, and dated. The Dietary Manager confirmed that eating outdated foods could pose a risk to residents' health, and staff were trained to properly store food by labeling and sealing it to reduce exposure to the elements.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure proper administration of medications through a G-tube for Resident #32, who was receiving enteral feeding due to dysphagia and aphasia following cerebrovascular disease. The resident, who had severe cognitive impairment and required a feeding tube for all nutrition and fluid intake, was observed receiving medications in a manner that did not comply with the facility's policy. LVN C crushed eight medication tablets together and attempted to administer them through the G-tube without dissolving each medication separately in water, as required by the care plan and physician orders. During the medication administration, LVN C used the plunger of the syringe to force the medications through the G-tube, which is against the facility's policy that mandates the use of gravity flow for administering medications and flushing the tube. This improper technique led to the G-tube becoming clogged, and LVN C had to use the plunger to unclog it, which could potentially cause irritation to the resident's stomach. Despite having received training on G-tube administration, LVN C did not follow the correct procedure due to nervousness during the observation. The Director of Nursing (DON) confirmed that the facility's policy requires each medication to be administered separately, diluted in water, and delivered by gravity flow. The DON emphasized that using the plunger could cause a rupture of the stomach and that the facility conducts yearly skills check-offs to ensure compliance with these procedures. The failure to adhere to these protocols placed Resident #32 at risk of not receiving proper nutrition and medication, as well as potential complications such as infection and aspiration.
Inadequate Respiratory Care Due to Equipment Oversight
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required oxygen management, as observed in the case of a male resident with a diagnosis of atherosclerotic heart disease. The resident's care plan indicated the need for oxygen therapy, and he was prescribed oxygen at 2 - 5 liters per minute by nasal cannula for shortness of breath or if oxygen saturation was below 93%. However, during observations, it was noted that the humidifier bottle attached to the oxygen concentrator was empty, and the concentrator's filter was covered with a thick, grey, powdery, dusty substance. Interviews with staff, including an LVN, the DON, and the Maintenance Director, revealed a lack of clarity and responsibility regarding the maintenance of the oxygen concentrator and humidifier bottle. The LVN acknowledged the oversight and stated that it was her responsibility to ensure the equipment was clean and filled. The DON and Maintenance Director also admitted that the oversight occurred due to a lack of a double-check system, which they planned to implement. The Administrator confirmed that the oversight was due to the failure of staff to follow policy and procedures. The facility's policies indicated that the maintenance department was responsible for keeping equipment in a safe and operable manner, while the oxygen administration policy required regular checks of the humidifier jar and oxygen tubing. Despite these policies, the oversight led to the resident receiving potentially inadequate oxygen support due to the dirty filter and empty humidifier bottle, which could affect the performance of the oxygen concentrator.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. For one resident, a medication aide left a Senna tablet at the bedside without ensuring it was taken, contrary to facility policy. The resident, who was cognitively intact, chose not to take the medication due to loose stools, and the medication aide did not report this to the licensed vocational nurse (LVN). This oversight was acknowledged by the medication aide and confirmed by the Director of Nursing (DON) and the Administrator, who reiterated the policy that medications should not be left at the bedside. In another case, a resident with a history of hypertension and hypotension did not receive midodrine as prescribed when her systolic blood pressure fell below the prescribed parameters on two occasions. The medication administration record (MAR) showed that carvedilol was held due to low blood pressure, but there was no documentation of midodrine being administered. The LVN and medication aide involved acknowledged the oversight, and the DON and Assistant Director of Nursing (ADON) confirmed that midodrine should have been given according to the physician's orders. These failures in medication administration could potentially impact the residents' well-being by not providing the necessary medications as prescribed. The facility's policy requires that medications be administered safely, timely, and as prescribed, which was not adhered to in these instances.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a resident with the prescribed controlled carbohydrate (CC) diet during breakfast meals on two consecutive days. The resident, who has diabetes and requires insulin, was given regular condiments such as syrup and jelly instead of the diet versions specified in her dietary plan. This oversight was noted during observations and interviews with the resident, who expressed concern about receiving incorrect condiments that could affect her blood sugar levels. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Nursing (DON), the Dietary Manager (DM), and the dietician, revealed a lack of adherence to the dietary plan. The LVN admitted to missing the regular jelly on the resident's tray, while the DM and dietician confirmed that the resident should have received diet jelly and syrup. Despite the dietary card clearly indicating the need for diet condiments, the resident continued to receive regular versions, highlighting a failure in the facility's food and nutrition services to ensure compliance with the prescribed therapeutic diet.
Involuntary Seclusion Due to Improper Use of Door Obstruction
Penalty
Summary
The facility failed to ensure the residents' right to be free from abuse, neglect, and involuntary seclusion. This deficiency involved two residents, one of whom was cognitively intact and the other severely cognitively impaired. The incident occurred when a CNA placed gloves in the door frame of the residents' room to prevent one resident from wandering, effectively confining both residents to their room. Resident #1, who was cognitively intact, was unable to open the door and had to use the call light to seek assistance. She was trying to leave the room to have her morning coffee but was unable to do so due to the obstruction. Resident #2, who was severely cognitively impaired and had a history of wandering, was unaware of the incident and remained in bed. The CNA responsible for placing the gloves in the door frame admitted to doing so to prevent Resident #2 from wandering while she attended to another resident. The incident was discovered when another CNA responded to the call light and found the door difficult to open due to the gloves. This CNA reported the incident to the DON, who initiated an investigation. The facility's policy clearly states that residents have the right to be free from involuntary seclusion, and the actions of the CNA were in direct violation of this policy.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving involuntary seclusion within the required two-hour timeframe to the State Survey Agency. This incident involved two residents who were secluded in their room by a CNA using gloves to block the door. The incident was reported to the facility's Director of Nursing (DON) by another CNA who discovered the situation when responding to a call light. The report indicates that the facility did not comply with the regulatory requirement to report such incidents promptly, which is a deficiency in their reporting procedures. Resident #1, a cognitively intact female with multiple diagnoses including diverticulitis, muscle weakness, and depression, was unable to exit her room due to the door being blocked. She required assistance with activities of daily living (ADLs) and used a rollator walker for mobility. Resident #2, who was severely cognitively impaired and an elopement risk, was also involved in the incident. She required moderate to maximum assistance with ADLs and used a wheelchair for mobility. The incident occurred when CNA A placed gloves in the door frame to prevent Resident #2 from wandering while she attended to another resident. The facility's policy on abuse investigation and reporting requires that all alleged violations involving abuse or neglect be reported immediately, but not later than two hours if they involve abuse or result in serious bodily injury. Despite this policy, the facility did not report the incident to the State Agency within the required timeframe. The deficiency highlights a failure in the facility's adherence to its own policies and regulatory requirements, potentially placing residents at risk of harm.
Incomplete Documentation of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurately documented. Specifically, the facility did not document a change in condition, physician notification, and transport to the hospital for a resident who was experiencing acute respiratory failure with hypoxia. The resident, a male with a history of dementia, hypertension, and other medical conditions, was admitted to the hospital with low oxygen saturation and tachycardia. On the day of the incident, a CNA observed the resident had vomited and reported this to an LVN, who then called a code and notified the physician via a secure message. However, the LVN did not document the change in condition, the physician's notification, or the transport to the hospital in the resident's electronic medical record (EMR). The LVN acknowledged forgetting to document these critical events due to the hectic nature of the situation. The facility's policy on charting and documentation requires that all services provided, changes in condition, and communications with physicians be documented in the resident's medical record. The Director of Nursing (DON) became aware of the documentation failure weeks later and emphasized the importance of completing documentation before the end of each shift to prevent delayed care for residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 275 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mont Belvieu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Burnet Bay | 0.7 mi | ★★★★★ | 4 | 0 |
| Rollingbrook Rehabilitation And Healthcare Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Focused Care At Allenbrook | 0.7 mi | ★★★★★ | 4 | 1 |
| Focused Care At Cedar Bayou | 1.3 mi | ★★★★★ | 2 | 0 |
| St James House Of Baytown | 3.7 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mont Belvieu Rehabilitation & Healthcare Center.
100% money-back within 48 hours.
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.