Focused Care at Humble

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 2 (Resident #47, Resident #38) of 17 residents reviewed for medication storage. The facility failed to ensure Resident #47's Tums (a fast-acting antacid that neutralizes stomach acid to relieve heartburn, acid indigestion, and upset stomach) were not left by the bedside on 7/13/26. The facility failed to ensure Resident #38's Systane (lubricant for eye drops) were not left by the bedside on 07/13/2026. This failure could place residents at risk of access to medications not approved for administration by their physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of 6 residents (Resident #66) reviewed for infection control. CNA A failed to perform hand hygiene with glove changes during incontinent care on Resident #66. These failures could place residents who required incontinent care at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents (Resident CR# 1) reviewed for quality of care.1. The facility failed to provide wound treatment according to the NP orders from 6/9/26 to 6/10/26 and from 6/16/26 to 6/20/26 for CR #1 who experienced a worsening sacral wound that increased in size and became infected. CR #1 was sent to the hospital on 6/20/26 and was diagnosed with severe sepsis with septic shock (life threatening condition where an infection triggers dangerously low blood pressure and organ dysfunction, requiring immediate medical intervention).2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights 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 for 1 of 5 residents (CR #1) reviewed for care plans. The facility failed to ensure CR #1's stage 3 sacral wound was care planned with interventions from 6/6/26 - 6/20/26. The failure could place residents at risk of worsening pressure ulcers and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from abuse and neglect, for 5 of 5 residents (Resident #1, Resident #2, Resident #4, Resident #8 and Resident #10) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse when CNA D forcefully pushed the resident down into the couch as the resident attempted to stand, causing the resident to cry and experience distress on 05/20/2026. The facility failed to protect Resident #2 from physical abuse when CNA D slapped the resident on the right arm, then grabbed his left arm and forcefully pulled him into a standing position, causing the resident to become unsteady and cry on 05/20/2026. [...]

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 (Resident #4) of 5 residents reviewed for pharmacy services. The facility failed to administer 4 doses of Clonazepam (medication used to treat seizures and anxiety) to Resident #4 between 05/8/26 - 05/10/26 because it was unavailable in the facility. Resident #4 had 3 back-to-back seizures and was sent to the hospital for treatment. This failure could place residents at risk of worsening of conditions and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments, including the storage of schedule II medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access except when the facility uses single unit medication distribution systems in which the quantity stored was minimal and a missing dose can be readily detected for 1 of 6 medication carts (600 hall) reviewed. The facility's medication cart was not kept locked or under direct observation of authorized staff in an area where residents could access it. No medications were taken by residents but the potential for more than minimal harm exists for 1 of 6 medication carts (600 hall) reviewed. The facility failed to ensure medications were stored and secured from unauthorized residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 8 residents (Resident #66) reviewed for advanced directives in that: 1. Resident #66 did not have his code status documented in the electronic record. This deficient practice could all residents as they may change their code status while being a resident at this facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (CR #1) reviewed for accidents. -CR #1 walked out of the facility unattended with a wander guard on and was missing for approximately 20 minutes on 8/6/24. The noncompliance was identified as PNC. The IJ began on 8/6/24 and ended on 8/9/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of elopement. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complication) for 1 of 7 residents (CR #1) reviewed for physician notification. -The facility failed to consult with the physician when CR#1 had a change in condition and continued losing weight, had a physical decline in performing ADL's, stopped eating and developed a burning in his throat. -The facility failed to notify CR#1's Family member when changes occurred. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 (CR#1) of 7 residents reviewed for neglect. -The facility failed to provide ADL care for CR#1 when he was transferred to the local hospital on 8/7/24 and CR#1 was found covered in fresh and dried feces and urine. These failures could place residents at risk of neglect and not having their care needs met, not being seen by physicians, not receiving adequate and timely interventions, which could cause a decline in physical and psychosocial health and even death.

Inspectors wroteBased on interviews and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 resident of 17 residents (CR #1) reviewed for quality of care. The facilities failure to assess CR#1 after she complained of pain during peri care at 5:00am on 06/06/24 but was not sent to the hospital until 06/07/24 at 12:06am which was over 18hours later. After being admitted into the hospital CR#1 was diagnosed with intertrochanteric fracture of the right femoral neck of indeterminate age. On 06/10/2024 at 3:46 p.m. an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interview, and record review the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 of 10 residents (CR#1) reviewed for radiology services: The facilities failure to assess CR#1 after she complained of pain during peri care at 5:00am on 06/06/24 but was not sent to the hospital until 06/07/24 at 12:06am which was over 18hours later. After being admitted into the hospital CR#1 was diagnosed with intertrochanteric fracture of the right femoral neck of indeterminate age. On 06/10/2024 at 3:46 p.m. an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store and serve food under sanitary conditions per professional standards for food service safety for one out of one kitchen and dining. -The facility failed to follow proper sanitation and food handling practices. -The facility failed to keep clean the ice machine used to distribute ice to the residents. -The DFS, FSA SS, and FSA TT did not follow proper sanitization procedures. -FSM QQ, FSA SS, and FSA TT did not follow proper food handler procedures. These deficient practices could put all 65 residents who received meals from the facility kitchen at risk of foodborne illnesses.

Inspectors wroteBased on interviews and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one of seventeen staff (CNA O) reviewed for staff qualifications. The facility failed to ensure CNA O was appropriately certified to practice and provide CNA care in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure clinical records were maintained in accordance with accepted professional standards and practices, were complete, and accurately documented for 1 (Resident #37) of 4 residents reviewed for clinical records. The facility failed to input treatment orders and document administration of those orders into the electronic health record for Resident #37's stage 3 pressure injury to right ischium, stage 3 pressure injury to right posterior thigh, and stage 3 pressure injury to left posterior thigh. These failures could place residents at risk for additional skin breakdown and inadequate care.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights and that included 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 were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for one of twelve residents (Resident #43) reviewed for care plans. -The facility failed to care plan for Resident #43 received hospice care services, or the hospice care services he was provided. These failures placed residents at risk of not receiving required medical and end of life care in a timely manner, of a full understanding of the care needs. Findings Included: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for one of twelve residents (Resident #58) reviewed for care plans. - The facility did not develop and implement a comprehensive person-centered care plan to address Resident #58' needs within 21 days of admission. - Resident #58's comprehensive person-centered care plan initiated on 01/25/2024 was not signed. These failures placed residents at risk for not receiving care and services to meet their medical, physical, and psychosocial needs. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents who are incontinent of urine received appropriate treatment and services to prevent urinary tract infections for 1 out of 5 residents (Resident #222) reviewed for incontinent care. - CNA B did not separate Resident #22's labia to clean and wiped from back to front during incontinent care. This deficient practice could place residents at-risk for infection due to improper care practices and decreased quality of life.

Inspectors wroteBased on observations, interviews, 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 10% based on 3 errors out of 28 opportunities, which involved 2 of 6 residents (Residents #34 and #27) reviewed for medication errors. MA I administered the wrong medication to Resident #34 according to Physician orders. MA JJ administered the wrong medication to Resident #27 and did not administer Vitamin D 50,000 units to Resident #27 as ordered by the Physician. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments and accessed only by authorized personnel for 2 of 6 residents (#64 and #21) reviewed for medication storage. Resident #64 had two boxes of Salonpas patches (temporary relief of minor aches) at the bedside and did not have a MD order to self-administer. Resident #21 had Nystatin powder (used to treat fungal infections) on the tv stand that CNAs applied during brief changes. These failures could place residents at risk of loss of their medications, inadequate therapeutic outcomes, or decline in health.