Mason Creek Transitional Care of Katy

Inspectors wroteBased on interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices on each resident that are complete and accurately documented for 1 of 5 (CR#1) residents reviewed for clinical records. The facility failed to maintain a complete and accurately documented clinical record for CR#1. This failure could place residents at risk of not getting the care and services to improve their quality of life due to not maintaining complete and accurate clinical records. Record review of CR#1's face sheet dated 5/14/2026 revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for two of eight medication carts observed for medication security. -An unlocked and unattended medication cart was observed in a resident hall (Hall 400). -An unlocked medication cart (Hall 300 Nurse's medication cart) was observed near the nurses' station, with the assigned nurse in another room with her back turned. The failure placed the residents at risk of drug diversion by staff, residents, and visitors, overdose, or residents' medications not being available when needed.

Inspectors wroteBased on observation, record review and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. - The facility failed to ensure food was labeled and dated. - The facility failed to ensure that food was off the floor in the dry food area. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation on 12/10/2024 at 08:53 AM, revealed in 1 of 1 walk in refrigerator a metal bowl with clear plastic wrap with a with no date or item description. [NAME] B took the bowl out of the refrigerator. [...]

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 18 residents (Residents #66) reviewed for care plans. Resident #66 did not have a care plan in place for the care and monitoring of her midline. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 (Residents #66) of 1 Residents reviewed for peripheral intravenous care. The facility failed to ensure Resident #66 had a physician order or care plan for the care and monitoring of her midline. The facility failed to ensure Resident #66's midline dressing was changed every 7 days per facility policy. The failures placed residents at risk of developing an infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, and administering medications for 1 (Resident #78) of 8 residents reviewed for pharmaceutical services. -Medication Aide A failed to administer the correct dosage for Resident #78's transdermal nicotine patch. -Medication Aide A failed to rotate the transdermal nicotine patch on Resident #78's body. This failure placed the resident at risk for skin irritation and not receiving the full intended therapeutic dosage of the medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 residents (Resident #78 and Resident #777) of 8 residents reviewed for infection control. -Mediation Aide A failed to sanitize blood pressure equipment after taking Resident #777's blood pressure. Medication Aide proceeded to take Resident #78's blood pressure. This failure placed the residents at risk for cross contamination, infections, and a decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed: - A roach was observed on a wall in the kitchen where food was being prepared for residents. These failures could place residents at risk for infections.

Inspectors wroteBased on observation, interview, and interview, 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 for 1 of 9 residents (CR #1) reviewed for change of condition. The facility failed to notify CR #1's physician or seek medical guidance when he experienced a drop in oxygen saturation during physical therapy just after breakfast on [DATE]. At approximately 3:00 p.m., CR #1 experienced a drastic desaturation (a decrease in oxygen saturation, low blood oxygen concentration) to 53% after a shower and resulted in loss of consciousness, initiation of CPR, and intubation (a medical procedure that involves inserting a flexible tube into the trachea to help maintain an open airway). CR #1 expired on [DATE] on hospice at his home. [...]

Inspectors wroteBased on observation, interview, and interview, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the resident's goals and preferences for 1 of 9 residents (CR #1) reviewed for respiratory care. 1. The facility failed to increase CR #1's oxygen or consult/seek further guidance from CR #1's physician to increase his oxygen to 6-8 L/min during a shower on [DATE] after his family members informed staff his oxygen requirement increased during exerting activities, including showers. The facility failed to monitor CR #1's oxygen administration/O2 levels while in the shower and ensure CR #1's oxygen was working properly or immediately call for a nurse when CNA A and CNA B noted a change of condition (CR #1's skin color was pale). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #1) reviewed for resident abuse. The facility failed to prevent Resident #1 from being physically abused by LVN B on 12/05/23. The noncompliance was identified as past noncompliance (PNC) IJ. The noncompliance began on 12/05/23 and ended on 12/12/23. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: -The facility failed to dispose of expired food items and keep Scoops stored outside of food bins. These failures could place residents at risk of food borne illness and diseases.

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 1 of 6 residents (Resident #60) reviewed for ADL care. 1. The facility failed to ensure Resident #60 was provided incontinent care in a timely manner . 2. The facility failed to ensure Resident #60 was provided grooming (dry skin) causing her skin to be dry and flaky. These failures could place residents at risk for discomfort, and dignity issues.

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 6 residents (Resident #60) reviewed for incontinent care. - The facility failed to ensure CNA M completely cleaned Resident #1 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility must dispose of 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.