Ffiii Houston SNF Tenant LLC

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 14%, based on 5 errors out of 34 opportunities, which involved 3 of 6 residents (Residents #47, #167 and #76) and 3 of 3 staff observed during medication administration reviewed for medication errors. 1. The facility failed to administer Resident #76's antibiotic, Bactrim (Sulfamethoxzole-trimethopine tablet) and Centrum Silver Gel as ordered by the physician on 8/27/25. 2. The facility failed to administer Resident #167's Pantoprazole before breakfast per the pharmacy label instructions on 8/27/25. 3. The facility failed to administer Resident #47's Rosuvastatin and Ipratropium Bromide nasal solution 0.03% 21 mcg as ordered by physician on 8/27/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and, in accordance with State and Federal laws, drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three of four medication carts (Nurse Cart 1B [middle Hall], Nurse Cart 2A Hall, Nurse cart 2B [middle Hall]) reviewed for storage of medications . The facility failed to ensure Nurse Cart 1B (middle Hall), Nurse Cart 2A Hall, Nurse cart 2B (middle Hall) did not have multiple medications opened and undated. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #119, Resident #182 and Resident #153) reviewed for infection control. 1. The facility failed to ensure C.NA A and LVN E used the required PPE for Resident #119, who was on enhanced barrier precautions while assisting with repositioning in bed, LVN E picked up blanket from the floor and placed on 8/26/25. 2. The facility failed to ensure LVN E used the required PPE for Resident #153 on 8/28/25. 3. The facility failed to ensure C.NA A maintained hand hygiene during incontinent/FC on 8/28/25 for resident #119. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #182) reviewed for ADL care. The facility failed to ensure C.NA A cleaned Resident #182 properly during incontinent/FC (Foley catheter) care on 8/28/25. This failure could place residents at risk for pain, infection and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #182) reviewed for incontinent care. 1. The facility failed to ensure CNA A cleaned Resident #182's indwelling Foley catheter properly.2. The facility failed to ensure CNA A followed proper hand hygiene during incontinent care on 8/28/25. 3. The facility failed to ensure CNA A secured Resident #182's Foley catheter. These failures could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #47) reviewed for medication administration. 1. RN B failed ensure she waited 3 to 5 minutes while administering Azelastine Hydrochloride and Ipratropium Bromide, nasal sprays, to Resident #47 on 8/27/25. (Azelastine Hydrochloride [helps relieve sneezing, itching and runny nose] and Ipratropium Bromide [helps open up the airways in your lungs to make breathing earlier]). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure services were provided or arranged by the facility, as outlined by the comprehensive care plan that met professional standards of quality for 2 of 6 residents (Residents #1 and Resident#3) reviewed for services. 1. The facility failed to ensure Resident #1 and Resident #3 received pressure sore treatment as ordered by the physician. These failures could place residents at risk of worsening of their pressure sores due to not getting the treatment as prescribed by the physician. 1. Record review of Resident #1's face sheet revealed an [AGE] year-old male originally admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 6 residents (Resident #1, Resident #3) reviewed for clinical records. 1. The facility failed to ensure Resident #1's pressure sore treatment form was accurate and complete with no blanks on the TARs on 6/18/2025, 6/23/2025, 6/25/2025 and 6/26/2025 and MARs on 6/19/2025. 2. The facility failed to ensure Resident #3's pressure sore treatment form was accurate and completed with no blanks on the TARs on 6/17/2025 and 6/20/2025 and on the MARs on 6/20/2025. These failures could place residents at risk of not receiving the care and treatment needed to improve their quality of life due to inaccurate or incomplete documentation. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 (CR#3) of 6 residents reviewed for comprehensive care plans. The facility failed to ensure that CR #3 had a comprehensive care plan that included all care areas triggered on her assessment. This failure could place all residents at risk of not receiving proper care and services to develop and improve their mental, physical and psychosocial well-being. Record review of CR#3's admission face sheet dated 7/18/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (CR#2) reviewed for services. The facility failed to ensure CR#2 received pressure sore treatment as ordered by the physician. These failures could place residents at risk of worsening of their pressure sores due to not getting the treatment as prescribed by the physician. Record review of CR#2's admission face sheet dated 7/1/2025 revealed an [AGE] year-old female who was admitted to the facility on [DATE] and was discharged on 6/24/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for one (Resident #1) of seven residents reviewed for change in condition. The facility failed to notify the NP immediately by phone call when Resident #1 was found on the floor holding his head and appeared confused after an unwitnessed fall. Resident #1 was sent to the hospital approximately six hours later and admitted to the ICU with a diagnosis of subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to follow up with the on-call physician after not receiving a response which delayed Resident #1's transport to the ER after an unwitnessed fall which resulted in a subarachnoid hemorrhage and 6 hour delay in care. Resident #1 was sent to the hospital and admitted to the ICU. An IJ was identified on 3/27/2025. The IJ template was provided to the facility on 3/27/2025 at 2:32 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received showers as scheduled. These failures could place resident#1 at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to facility must develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of eighteen (Resident #25 and Resident #86) residents reviewed for comprehensive person-centered care plans. -The facility failed to develop a care plan with measurable objectives and time frames for Resident #25 and Resident #86 related to communication methods, ADL needs, and preferences. -The facility failed to document care plan for Resident #25's use of a catheter. [...]

Inspectors wroteBased on record review and interviews, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for two of eighteen (Resident #27 and Resident #35) of eighteen residents reviewed for MDS assessments. -The facility failed to complete Resident #27 and Resident #35's quarterly MDS assessment within three months of their most recent comprehensive assessment. This failure could lead to residents not receiving care required for their individualized needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of two walk-in freezer's observed. -The facility failed to ensure a tub of ice cream was stored with a lid and was open in the walk-in freezer. This failure could have placed residents who ate the ice cream at risk for illness from food-borne pathogens.

Inspectors wroteAbbreviations: ADON - Assistant Director of Nursing AS-Agency Staff BIMS-Brief Interview for Mental Status CO2-Carbon Dioxide DORC - Director of Resident Care DON - Director of Nursing ED - Executive Director FM-Family Member LVN-Licensed Vocational Nurse R-Resident MAR-Medication Administration Record MDS-Minimum Data Set MT - Resident Medication Technician OMB - Ombudsman O2-Oxygen RA-Resident Assistant RN-Registered Nurse PA Private Aide PICC-Peripherally Inserted Central Catheter SW-Social Worker TAR-Treatment Administration Record RN-Registered Nurse IT-Immediate Threat Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for indwelling [...]

Inspectors wroteAbbreviations: ADON - Assistant Director of Nursing AS-Agency Staff BIMS-Brief Interview for Mental Status CO2-Carbon Dioxide DORC - Director of Resident Care DON - Director of Nursing ED - Executive Director F/C-Foley Care FM-Family Member LVN-Licensed Vocational Nurse R-Resident MAR-Medication Administration Record MDS-Minimum Data Set MT - Resident Medication Technician OMB - Ombudsman O2-Oxygen RA-Resident Assistant PA Private Aide PICC-Peripherally Inserted Central Catheter SW-Social Worker TAR-Treatment Administration Record RN-Registered Nurse IT-Immediate Threat Based on interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for parenteral intravenous (IV)/ peripherally inserted central catheter (PICC) therapy. [...]

Inspectors wroteAbbreviations: ADON - Assistant Director of Nursing AS-Agency Staff BIMS-Brief Interview for Mental Status CO2-Carbon Dioxide CNS-Central Nervous System COPD-chronic obstructive pulmonary disease DORC - Director of Resident Care DON - Director of Nursing ED - Executive Director F/C -Foley Catheter FM-Family Member LVN-Licensed Vocational Nurse R-Resident MAR-Medication Administration Record MDS-Minimum Data Set MT - Resident Medication Technician OMB - Ombudsman O2-Oxygen RA-Resident Assistant PA Private Aide PICC-Peripherally Inserted Central Catheter SW-Social Worker TAR-Treatment Administration Record RN-Registered Nurse IT-Immediate Threat Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #2) [...]

Inspectors wroteAbbreviations: ADON - Assistant Director of Nursing AS-Agency Staff BIMS-Brief Interview for Mental Status CO2-Carbon Dioxide DORC - Director of Resident Care DON - Director of Nursing ED - Executive Director F/C-Foley Catheter FM-Family Member LVN-Licensed Vocational Nurse R-Resident MAR-Medication Administration Record MDS-Minimum Data Set MT - Resident Medication Technician OMB - Ombudsman O2-Oxygen RA-Resident Assistant PA Private Aide PICC-Peripherally Inserted Central Catheter SW-Social Worker TAR-Treatment Administration Record RN-Registered Nurse IT-Immediate Threat Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for one (RN B) of 2 staff members reviewed for infection control. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 3 of 53 residents (Resident #21, Resident #38, and Resident #41) reviewed for discharge MDS assessments. The facility did not ensure Resident #21, #38, and #41's discharge MDS assessment was completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 16.67%, based on 5 errors out of 30 opportunities, which involved 4 (Residents #47, #50, #23 and #27) of 10 residents reviewed for medication errors. The facility crushed medications without a physician's order, and administered these medications to Resident #47, #23 and #27. The facility failed to administer Resident #50's antibiotic, Cefpoxidime with food as per pharmacy label instructions. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 (Resident #47) of 10 residents reviewed for safe administration of medications, in that: -The facility failed to administer the correct number of Anagrelide capsules (a blood thinner to treat elevated blood platelet counts) daily as ordered by the physician to Resident #47 4 days over 14 days. This deficient practice could affect all residents who receive medication from the facility and place them at risk for inadequate therapeutic outcomes, increased negative side effects, decline in health, hospitalization, or death. Record review of Resident #47's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for three (Nurse Cart 2B Hall, Med Aide Cart 1A Hall, Nurse cart 2A Hall) of four medication carts reviewed for storage of medications. Nurse Cart 2B Hall, Med Aide Cart 1A Hall and Nurse cart 2A Hall had punctured protective seals on the back of multiple narcotic medication blister pill cards. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and/or serve food in accordance with professional standards for food service safety in 1 of 3 kitchens reviewed for food procurement in that: Facility failed to maintain proper storage, label and/or date. These failures could place residents at risk of foodborne illnesses and disease.