Fort Bend Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administration of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #26 and CR#1) of 6 residents reviewed for pharmacy services. -Resident #26's physician's order for Calcium-Vitamin D Tablet 600-200 MG-UNIT was not administered as ordered on 08/06/2025. Residents #26's physician order for supplement 30 ml order date was not given as ordered on 7/6/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician of a significant change in the resident's physical status such as a deterioration in health and a need to alter treatment significantly such as discontinuing an existing form of treatment for 1 (CR#1) of 5 residents reviewed for physician notification. RN A failed to notify CR#1's physician- when RN A discovered CR#1's IV was dislodged on 8/5/2025 around 9:15am and needed to be discontinued.-when RN A discovered CR#1 had low blood pressure and pulse on 8/5/2025 around 9:15 a.m. and CR#1 was pronounced dead at the facility on 8/5/2025 at 10:56am. This failure could place other residents at risk of not being assessed and receiving care in a timely manner, potentially leading to injury, harm or death. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (including to the State Survey Agency and adult protective services) for 1 (Residents #58) of 5 residents reviewed for reporting allegations. -The facility failed to report Resident #58's unwitnessed fall. Resident #58 had limited mobility. This deficient practice could place residents at risk for abuse, neglect, exploitation, and or mistreatment. [...]

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 that will mean each resident's physical, mental and psychosocial needs for 1 (CR#1) of 5 residents reviewed for quality of care.-RN A failed to properly complete assessments for CR#1 when RN A found CR#1 had low blood pressure and low pulse and had her IV dislodged on 8/5/2025 around 9:15am. CR#1 was pronounced dead on 8/5/2025 at 10:56am. This failure to accurately assess resident health status for potential interventions in a timely manner could lead to harm, injury and death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #65) of 2 residents observed for indwelling urinary catheters. -The facility failed to ensure CNA A provided appropriate care for Resident #65 during Foley catheter care. Resident #65's indwelling catheter was not secured to his thigh, his catheter bag was placed on the bed when it should have been emptied before incontinent care. CNA A did not open Resident #65's labia to clean and did not clean the catheter from the insertion site. This failure could place residents at risk for urinary tract infection, discomfort, skin breakdown and decreased quality of life. Record review of Resident #65's face sheet revealed 78 years- old female was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were secured and stored properly for one of three medication carts (100 Hall Nurse Medication Cart) reviewed for drug storage. - UM failed to ensure 100 hall Nurse medication cart was locked when left unattended on 08/07/2025. -There were 4 over-the-counter medications observed opened with no date in the medication cart on 08/07/2025, including 24-hour Allergy Nasal spray, Latanoprost Sol 0.005%, Geri-Tussin -Guaifenesin (expectorant), and Milk of Magnesia. These failures could place residents at risk for possible drug diversions or accidental ingestion. During observation on 8/7/25 at 1:35PM, medication cart on 100 hall was left unlocked and there was no nurse around the medication cart. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to perform an appropriate assessment on Resident #1 after report of an unwitnessed fall on 12/31/24 that resulted in a hip fracture that required hip surgery. The facility failed to initiate neuro checks for Resident #1 after report of unwitnessed fall. An Immediate Jeopardy was identified on 4/4/25. The Immediate Jeopardy template was provided to the facility on 4/4/25 at 11:26 a.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the comprehensive person-centered care plan was reviewed and revised after a change in condition and or falls for 1 (Resident #1) of 4 residents reviewed for care plan revision/timing. 1. The facility failed to ensure Resident #1's care plan was revised to include interventions and services to decrease the risk of falls in the facility's dining room after suffering a fall on 12/31/24. Resident #1 had similar falls in the facility's dining room on 09/29/23 and 09/21/24 with no injuries. 2. The facility failed to ensure Resident #1's care plan included interventions and services to appropriately assess and monitor the resident's chronic pain. These failures could place residents at risk of not receiving the appropriate care, services, or treatments needed to achieve highest quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater. The facility had an error rate of 6%, based on 2 errors out of 29 opportunities, which involved two of four residents (Resident #94 and Resident #38) and two of four staff (LVN B and RN A) observed during medication administration reviewed for errors. -LVN B failed to administer Thiamine 100 mg tablet to Resident #94 because it was not available. -RN A failed to administer Metoprolol 50 mg to Resident #38. These failures placed residents in the facility at risk for inadequate therapeutic outcomes and decline in health. Findings Include: Resident #94 Record review of the Face Sheet (run time 06/27/24 at 5:12 p.m.) for Resident #94 revealed he was [AGE] years old and was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for one of two controlled medication count sheets (hall 100) reviewed for the shift-to-shift reconciliation. -The facility staff failed to follow their policy to perform shift counts/audits at shift change and complete the log. -The Controlled Drugs-Count Record for Hall 100 had blanks for previous shift counts/audits. -The blanks in the Controlled Drugs-Count Record for Hall 100 were filled in days later. LVN D, who filled in the blanks could not provide an explanation. The failures placed residents at risk for not having medications available in case of drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 3 of 8 residents (Resident #3, #4 and #17) reviewed for infection control in that: -MA BB did not wash or sanitize her hands before entering Resident #3 and #17's room to check their vital signs. -MA BB did not disinfect the wrist blood pressure monitor in between Resident #3 and #17 when checking their vital signs. - CNA A and CNA B stored dirty linens and soiled brief trash bags on the floor in Resident#195's room. - The facility failed to date Resident #4's suprapubic catheter drainage bag according to their policy. These failures could affect residents and place them at risk of cross contamination and blocked urinary catheters.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of abuse was reported to State Agency within 24 hours for 1 of 1 resident (Resident #11) reviewed for self-reporting abuse. The facility did not report to the State Agency within 24 hours when an outcry of abuse was made by Resident #11 during a group meeting. This failure could place residents at risk of harm due to delays in reporting an allegation of abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #195) reviewed for incontinent care. The facility failed to ensure CNA A and CNA B properly cleaned Resident #195 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown and a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 (Resident #34) of 8 residents reviewed for storage of medications. The facility failed to ensure Resident #34's medication was kept in a secure location. Resident #34 had medicated ointment at the bedside. This deficient practice could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a hospice election form, hospice plan of care, the physician certification and recertification specific to the terminal illness, and hospice medication information form for 1 (Resident #38) of 1 resident reviewed for hospice care. This deficient practice could place residents who receive hospice services at risk for receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.