Focused Care at Cedar Bayou

Inspectors wroteBased on record review and interview, the facility failed to transmit accurate, encoded, complete MDS assessments to the CMS system within 14 days of admission for 1 of 17 residents records reviewed for MDS transmission (Residents # 68). The facility failed to ensure that CR 68's admission MDS dated [DATE] was completed within 14 days of admission. This failure put residents at risk of not having their assessments completed timely which could result in denial of services or denial of payment for services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (Resident #22) of 6 residents reviewed for accuracy of assessments. The facility failed to accurately complete the MDS assessment to indicate Resident #22 did not receive insulin. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Record review of Resident #22's face sheet dated 6/18/2026 revealed she was admitted into the facility originally on 11/16/2018 and readmitted on [DATE] with diagnoses that included Parkinsonism (an umbrella term that refers to conditions with similar, movement-related effects). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was not greater than 5 percent or greater. The facility had a medication error rate of 16.67% based on 5 errors and 30 opportunities which involved 3 of 4 residents (Resident #71, Resident #62, and Resident #11) reviewed for medication administration.1. RN A failed to administer 3 medications separately through Resident #71's gastrostomy tube (G-tube). 2. RN A failed to flush in between administering medications through Resident #11's G-tube. 3. RN B failed to administer the correct order of Senna oral tablet 8.6 mg to Resident #62. RN B administered Senna Plus 50 mg to Resident #62. These failures could place residents at risk of increased hospitalization, adverse side effects, and a decline in health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 communicate disease and infections for 2 of 4 residents reviewed for infection control. RN A failed to utilize PPE prior to administering medication to Resident #71 through a gastrostomy tube. RN B failed to use clean technique while preparing medication for Resident # 62 by placing a medication capsule into her left hand before placing the capsule into a medication cup. RN B failed to perform hand hygiene after administering medication and exiting Resident #62's room. This failure could place residents at risk by exposing them to care that could lead to the spread of infection and communicable diseases. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician and resident's representative when there was a deterioration in the resident's physical and mental status for 1 of 1 CR (CR #1). The facility failed to notify the resident's physician and the resident's representative of CR #1's restless nighttime behavior with repeated attempts to get out of bed and crawl onto the floor, and the need for a mattress on the floor for CR#1 to sleep on. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of the resident for 1 (CR#1) of 1 resident reviewed for baseline care plans. The facility failed to provide the CR#1's representative with a summary copy of the baseline care plan. The facility failed to incorporate CR#1's sleeping preferences in the baseline care plan. This failure could result in residents not receiving inadequate care or having their needs met. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1 of 5 residents (CR#1) reviewed for physician notification. The facility failed to properly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure. The facility failed to notify physician after CR#1's vitals were declining, which lead to CR#1's hospitalization with vital organ impairment or failure. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at 5:30 p.m. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure CR#1 received treatment and care in accordance with professional standards of practice for 1 of 5 residents (CR#1) reviewed for quality of care. The facility failed to properly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure. The facility initially became aware of CR#1's declining vitals on 5/2/25 at 10:18am based on the timeline of vitals listed in nursing notes. 911 was not called until 5/3/25 at 5:30pm, which was more than 24 hours later. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at 5:30 p.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plans for one (Resident #1) of seven residents reviewed for comprehensive care plans in that: The facility failed to notify the PCP according to the resident care plan and physician orders when Resident #1's blood sugar level was over 401 after a blood sugar level check on 6/9/2025. This failure could place the residents at risk of harm, injuries, and delayed treatment.

Inspectors wroteBased on interview and record review, the comprehensive assessment of a resident, the facility must 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 5 residents (CR #1) reviewed for quality care. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (CR #1) reviewed for pharmacy services in that:. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (CR #1) reviewed for significant medication errors. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents reviewed for pain management. The facility failed to provide medications Hydrocodone-Acetaminophen 10- 325mg per order for Resident #129 when admitted on [DATE] and after Resident #129 complained of continued pain and requested medication. No pain medication was provided until 2/6/24 when MD visited and changed medication orders. An Immediate Jeopardy (IJ) situation was identified on 2/08/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide routine and emergency drugs for 1 of 8 residents (Resident #129) reviewed for pharmacy services. -The facility failed to provide Resident #129 with ordered routine medications, Eliquis 5mg (blood thinner) and Hydrocodone-Acetaminophen 10- 325mg (pain medication) upon admission and for two days thereafter resulting in the resident experiencing continued pain. An Immediate Jeopardy (IJ) situation was identified on 2/08/2024. The IJ template was provided to the facility on 2/08/2024 at 3:03 PM. While the IJ was removed on 2/11/2024, the facility remained out of compliance at a severity level of potential harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure one of twelve residents (Resident #3) reviewed for abuse, neglect, and/or exploitation remained free of abuse. -Resident #3 alleged that LVN B kicked her in her side/back after she had fallen in her restroom in November 2023 This failure could place residents at risk for abuse, pain, fear, and psychosocial impairment. The noncompliance was identified as PNC. The IJ began on 11/20/2023 and ended on 11/21/2023. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #18) of 6 residents reviewed for accidents hazards/supervision. The facility failed to prevent Resident #18 from eloping from the facility without the staff's knowledge despite the resident wearing a wander guard. The facility failed to ensure the facility exit doors were secured/locked to prevent resident elopement. An Immediate Jeopardy was identified on 02/08/24. The Immediate Jeopardy was lowered on 02/11/24; however, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 10 residents (Resident #129) reviewed for care plans, in that: -A baseline care plan was not completed for Resident #129 within 48 hours of admission. This failure could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and failed to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 12 residents (Resident #57) reviewed for care plans. -The facility failed to document the care plan with the use of Resident #57's scoop mattress usage. This failure could place residents at risk of attaining/maintaining their highest practicable physical, mental, and psychosocial well-being.

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 6 % based on 2 errors out of 32 opportunities, which involved 1 of 8 residents (Resident #64) reviewed for medication errors, in that: MA Q failed to give Resident #64 her Sevelamer Carbonate (a medication used to lower blood phosphorus levels in patients on dialysis due to kidney disease) as ordered by her physician with meals and Carvedilol (medication used to treat high blood pressure and heart failure) as directed by pharmacy with meals. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services: -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 3 of 15 residents reviewed (Resident #13, #20, & #38 ) reviewed for comprehensive assessments and timing. 1. The facility failed to ensure Resident #13's most recent comprehensive MDS assessment accurately reflected her functional limitation of upper extremities and her oral cavity. 2. The facility failed to ensure Resident #20's most recent comprehensive MDS accurately reflected her mental condition. 3. The facility failed to ensure Resident #38's most recent comprehensive MDS accurately reflected his oral cavity. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assure that there was sufficient qualified nursing staff available at all times (24-hours). The facility failed to provide 24-hour licensed nursing (registered nurse) coverage November 21 - 26 and November 28th and 29th of 2022. This failure could place residents at risk of not receiving related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 4 residents (Resident #3 and Resident #22) reviewed for pharmaceutical services. - The facility failed to administer medications to Resident #3 correctly by crushing and administering multiple pills together. - The facility failed to administer BP medication to Resident #22 as ordered by administering Midodrine (a medication for increasing low blood pressure) outside of physician ordered parameters. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 (Resident #20) reviewed for PASARR. Resident #20 with diagnoses of mental illness did not receive a PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means and received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #13) reviewed for gastrostomy tube management. - LVN B failed to follow Resident #13's physicians orders and facility policy by dissolving medication for administration in 20-30 ml of water instead of 5 ml. - LVN B failed to check for placement prior to use of Resident #13's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) by injecting 30 ml of water by syringe instead of air and failing to listen for bowel sounds. - LVN B failed to flush Resident #13's G-tube correctly by injecting 30 ml of water by force using a syringe instead of allowing the water to flow by gravity. [...]