Heritage Park of Katy Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider and before transferring or discharging to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 2 (Resident #2) residents reviewed for proper discharge. -The facility did not send a copy of Resident #2's 30-day discharge notice of the intended discharge date to the Ombudsman at the same time the facility notified Resident #2 on 06/17/2026. The Ombudsman was first notified of Resident #2's discharge on [DATE] by e-mail exchange. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled drug counts were in order and reconciled for two of two medication carts observed during change-of-shift. -Two medication carts controlled medication counts were conducted without staff cross-checking the medications cards and controlled medication count sheets. -The staff did not state the name of the medication when calling out the resident name and quantity. -The facility policy did not require both staff to confirm the quantity being verbalized was the quantity written on the controlled medication count sheet. The failure placed residents at risk for controlled medications to not be available when needed, and for controlled drug diversion.

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 for 1 of 1 kitchen in that: -Five dented cans were stored with other cans used for resident meals in the dry storage room. -Food items were not sealed and not dated in the dry storage room. These failures could place residents who received meals from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level 1 Residents with a positive trigger for mental illness were provided with a PASRR Level II assessment for 1 (Resident #79) of 5 residents reviewed for mental illness. The facility did not correctly identify Resident #79 as having mental illness in her PASRR Level 1 Screening. This failure could place five residents with psychiatric diagnoses to trigger a positive PASRR Level I evaluation at risk for not receiving a PASRR Level II screening and receiving needed care and services to meet their needs.

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (Resident #26) of 31 residents reviewed for base-line care plans. The facility failed to ensure (Resident #26) had a baseline care plan developed within 48-hours after admission with goals based on admission orders and interventions, PASRR recommendations, Physician's orders, therapy services, dietary orders, and social services. This failure could place newly admitted residents at risks of not receiving the proper care and continuity of services.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (100 Hall Nurse Medication Cart) of four medication carts reviewed for storage of medications. The Nurse Medication Cart for 100 Hall had a torn protective seal on the back of Resident #211's Tramadol HCL 50mg (a narcotic used to treat moderately severe pain) medication blister pill card (a type of medication packaging, with multiple small, sealed compartments that hold individual doses of medication) found in the locked narcotic drawer during review of medication carts. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, infection, and drug diversion.

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 2 of 4 residents (Resident #1, and Resident #3) reviewed for incontinent care. - 1. The facility failed to ensure Resident #1's foley tubing was not touching the floor while Resident #1 was propelling himself between the nursing station and medication room. - 2. The facility failed to ensure Resident # 3's foley bag and tubing were not touching the floor while Resident #2 was laid in bed. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 2of 5 residents (Resident #2, and Resident #3) reviewed for call lights. The facility failed to have call light was within reach for Resident #2 and Resident #3 while the residents was in bed. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life.

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 (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #4) reviewed for ADLs. 1. The facility failed to ensure Resident #4 was provided personal grooming (fingernail care) by facility staff. This failure could place residents at risk for discomfort, and dignity issues.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 4 residents reviewed for care plans (Resident #50) - The facility failed to care plan Resident #50's risk and history of falls and to put interventions in place to prevent further falls. The care plan was not updated or revised after each fall. An Immediate Jeopardy (IJ) was identified on 09/24/23 at 2:00 PM. While the IJ was removed on 09/26/23 at 4:32 AM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of not having individual needs met and decreased the quality of life to prevent further falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #50) reviewed for free of accidents, hazards, supervision, and devices., in that: 1. The facility failed to provide and utilize assistive devices for Resident #50 who had experienced multiple falls and unwitnessed fall on 7/25/23. Interventions including assistive devices were not put in place after a fall on 07/25/23 resulting in hospitalization and resident fell again on 07/26/23 resulting in a major head injury and another hospitalization 2. The facility failed to implement interventions after each fall incident for Resident #50 on 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023 and 9/3/2023. [...]

Inspectors wroteBased on observation , interview, and record review, the facility failed to ensure allegations of abuse and neglect are thoroughly investigated and report results of the investigation to the stage agency within 5 working days of the incident for 2 of 9 residents (Resident #50 and #84) reviewed for allegations of neglect as evidence by: 1. The facility failed to report an unwitnessed fall to the state agency when Resident #84 was found on the floor had a large hematoma to the top of her head and was transferred to the hospital . Resident #84 could not state how she fell. 2. The facility failed to report an unwitnessed fall to the state agency when Resident #50 was found on the floor. Resident #50 was sent to hospital on 7/25/23 and returned 12:30 AM on 7/26/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis service was provided consistently with professional standards of practice for 1 of 3 residents (Residents #72) reviewed for dialysis services. The facility failed to keep ongoing communication with the dialysis facility for Resident #72. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, 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 8 (Resident #32) reviewed for medication administration. The facility failed to ensure that LVN A did not administered Resident #4's Prednisolone Acetate Ophthalmic (eye drop medication used to treat inflammation of the eyes) to Resident #32. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biological's 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 when applicable for 2 of 4 medication Carts reviewed for medication storage. The facility failed to ensure the medication (med) chart 100-hall did not have the expired medications Packets of Arginaid ( Arginne powder) ( used to help support the unique nutritional needs of individuals with wounds). The facility failed to ensure the Nurses medication carts 300-hall did not have the opened and undated medications: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an adequately furnished space for dining and activities for 1 of 1 dining room and 1 of 1 activity room reviewed for dining and activity rooms. The facility did not provide an adequately furnished dining room or activity room for dining and resident activities. This failure could place the residents at risk for psychosocial harm and decreased quality of life.