Houston Heights Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 10 residents (Resident #13 and Resident #28). The facility failed to ensure that PASARR requested therapy services were provided to Resident #13 and Resident #28 in accordance with the PCSP meeting to include Occupational Therapy, Physical Therapy, and Speech Therapy. This failure could result in not receiving the support necessary to maintain stability, function, and safety.

Inspectors wroteBased on observation, 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 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 1 of 8 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure that Resident #1's care plan included interventions for the contractures to the left elbow, left hand, right knee and left knee. The facility failed to ensure Resident #1's care plan included heel protectors for the potential for the development of pressure ulcers and for the non-pressure wound to the left foot. [...]

Inspectors wroteBased on interviews and record review failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision, in that: CR #1 eloped from the facility on 6/21/25 after being let out of the building by the Receptionist. CR #1 was found by another staff member on the sidewalk near the carwash which was next door to the facility. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/21/25 and ended on 06/21/25. The facility corrected the non-compliance before the survey and investigation began on 06/24/25. The IJ template was sent to Administrator on 06/26/25 at 11:40a.m. This failure could place the residents with exit seeking behaviors at risk for injury or death.

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% based on 4 errors out of 25 opportunities which involved 3 of 5 residents (Residents #4, #63 and #89) and 3 of 5 staff (RN C, MA A, and LVN O) reviewed for medication administration.1. RN C crushed and administered enteric coated Aspirin 81 mg (a formulation of aspirin, that should not be crushed, that has a special coating to prevent it from dissolving in the stomach) to Resident #4 on 6/25/25.2. MA A administered Sennosides instead of Sennosides with Docusate according to physician orders and failed to administer the prescribed amount of Clearlax (Miralax/Polyethylene Glycol 3350) to Resident #63 on 6/25/25. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident #81) out of eight residents reviewed for ADLs. The facility failed to provide personal hygiene to Resident #81 which resulted in patches and dry flaky skin from below the knee to her feet . These deficient practices could place residents at risk of skin breakdown, and reduced feelings of self-worth.

Inspectors wroteBased on observation, interviews, and record review the facility failed to have physician orders for the resident's immediate care at time of admission for 1 of 5 residents (Resident #1) reviewed for physician admission orders. The facility failed to provide physician orders for Resident #1 when admitted to the facility with a need for knee immobilizer on 02/18/25. This failure could place the residents at risk of not receiving necessary physician ordered care that could result in worsening conditions or decline in health.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were free from verbal abuse for 2 of 9 residents (Resident #2 and Resident #3) reviewed for abuse. - The facility failed to prevent verbal abuse by DON K. On 11/20/24 DON K told Resident #2 she would send him to jail if he did not shut up. - The facility failed to prevent verbal abuse by DON K. On 1/30/25 DON K got in Resident #3's face and yelled at her to shut up. These failures could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents and supervision. Resident #1, who ambulated via motorized wheelchair, sustained minimally displaced fractures of the 2nd through 4th metatarsal necks (breaks in the long bones in the foot, specifically the part connecting the bone to the foot's arch) on 03/21/2025 when CNA A failed to turn off the wheelchair while providing care and bumped into the joystick (the mechanism that moves the wheelchair) which caused the wheelchair to propel forward and slam Resident #1's feet into a wall in the shower room. This failure placed residents who ambulate via motorized wheelchair at risk of injury, pain, and anxiety of possible recurrence.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 10 residents (Resident #1) reviewed for changes of condition. The facility failed to notify Resident #1's physician when she experienced a change of condition, including SOB and desaturation (low blood oxygen levels) on 06/05/2024. This failure placed residents at risk experiencing a delay in medical treatment and worsening of condition/symptoms.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to report an alleged violation of abuse to HHSC for 1 of 10 resident (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to report an allegation of abuse to HHSC after Resident #1's family member expressed concerns when CNA C allegedly handled the resident roughly during resident care. This failure placed residents at risk of continued abuse, neglect, or exploitation.

Inspectors wroteBased on interviews and record reviews, 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 ten residents reviewed for quality of care. 1. The facility failed to ensure Resident #1, who had a history of SOB, was sent to her dialysis treatment with oxygen equipment on 06/05/2024 and resulted in an episode of desaturation (low blood oxygen levels) and SOB. 2. The facility failed to ensure Resident #1 was sent to her dialysis treatment with a mechanical lift pad, as ordered by her physician, on 06/05/2024 and 06/12/2024 and resulted in a delay in receiving her dialysis treatment. [...]

Inspectors wroteBased on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions for level II resident review upon a significant change in status assessment for one of nineteen residents (Resident #33) reviewed for PASARR evaluations. The facility failed to refer Resident #33 to the appropriate, State-designated authority when she was diagnosed with MI. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health.

Inspectors wroteBased on interview and record review the facility failed to indicate accurately in the assessment, the resident's cognitive status for one of nineteen residents (Resident #69) reviewed for assessment accuracy. - The facility failed to accurately document in the assessment of Resident #69's impairments of both lower extremities. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care.

Inspectors wroteBased on observations, interviews, 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 for 2 of 18 residents (Resident #67 and Resident #301) reviewed for pharmacy services. -The facility failed to order Resident #67's medication correctly and he was not getting it for 2 days. -MA A applied Resident #301's Lidocaine patch to the right knee instead of the left thigh according to Physician orders and did not remove the previous Lidocaine patch prior to applying the new one. -The Lidocaine patch was on Resident #301 longer than the recommended timeframe as specified by the Manufacturer instructions and MD. This failure could place residents at risk of inadequate therapeutic outcomes and worsened health conditions.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents hazards. The facility failed to ensure that Resident #1, who was a two-person transfer using the mechanical lift . was transferred using the mechanical lift instead of a one-person manual lift. Resident #1 sustained a tibial plateau fracture to the right knee (a break at the top of the shinbone involving the cartilage surface of the knee joint). An Immediate Jeopardy (IJ) was identified on 03/18/2024 at 2:30PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/18/2024 at 2:30PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing staff were licensed for 1 of 10 staff (LVN A) reviewed for competencies. The facility failed to ensure LVN A's license was valid in order to practice as a licensed vocational nurse. This failure could place residents at the facility at risk of not receiving care and services from staff who are properly trained.

Inspectors wroteBased on interviews and record reviews, the facility failed to consult with the resident's physician of 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 complications) for 1 (Resident #4) of 5 residents reviewed for resident rights. -The facility failed to notify and document notification of physician when LVN K rounded on Resident #4 and found oxygen saturation to be 85%. On [DATE] at 2:00 p.m an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 of 1 resident (Resident #4) reviewed for basic life support, including CPR. -The facility failed to retrieve the automatic external defibrillator (AED) and initiate the basic life support sequence of events (chest compressions, airway, breathing) per the facility's Emergency Procedure- Cardiopulmonary Resuscitation Policy (CPR) for Resident #4. On [DATE] at 2:00 pm an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 2 out of 12 residents (Resident #1 and Resident #2) reviewed for comprehensive care plans. -The facility failed to ensure Resident #1 and Resident #2 had a code status that was care planned. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used were labeled in accordance with currently accepted professional principles, which included the appropriate accessory and cautionary instructions, and the expiration date when applicable and the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 5 medication carts (300 Hall Nursing Cart and 500 Hall medication Aide Cart) reviewed for medication storage. - The facility failed to ensure the 300 Hall Nursing Cart did not contain Albuterol inhalation solution without a pharmacy label and insulin pens without open dates. [...]

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 resident rights, 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 to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Residents #101 and #267) reviewed for care plans. The facility failed to ensure Resident #101 and Resident #267's comprehensive care plan included the care for residents with a pacemaker. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, which included 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 6 residents (Residents #47) reviewed for pharmacy services. - The facility failed to ensure Resident #47's Humulin 70/30 Insulin pen was within date prior to administering the medication. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -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.