Mont Belvieu Rehabilitation & Healthcare Center

Inspectors wroteBased on interviews and record reviews, the facility failed to utilize the services of a RN for 8 consecutive hours 7 days a week and designate a RN as a DON on a full-time basis for 1 of 1 facility reviewed for nursing services. The facility failed to ensure an RN worked for 8 consecutive hours for 4 of 30 days reviewed in February and March 2026. The facility failed to designate an RN as a DON on a full-time basis for 2 of 2 months reviewed in February and March 2026. These failures could place residents at risk of not having their nursing and medical needs met, and other direct care staff not receiving sufficient oversight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 23 residents (Resident #14) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #14's admission MDS assessment dated [DATE] and the most recent MDS quarterly assessment 01/28/2026 to ensure Resident #14 dental status when she had missing teeth and dental concerns. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications for 1 of 18 residents (Resident #55) reviewed for unnecessary medications. The facility did not monitor Resident #55's apixaban (blood thinner) medication for side effects. This failure could place residents at risk for unintended, harmful events attributed to the use of medication without monitoring for side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 23 residents (Resident #14) reviewed for dental care. The facility did not assist Resident #14 with obtaining dental services when she had dental concerns of missing, broken and loose teeth. This failure could cause the resident unnecessary dental pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accident hazards/supervision/devices. The facility failed to ensure CNA A used a gait belt when transferring Resident #1 from her wheelchair to the bed on 03/10/2026. This failure could place the residents at risk for discomfort, pain, falls, injuries, and skin tears.

Inspectors wroteBased on interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control. RN A failed to properly dispose of used sharps on [DATE] and they were left hanging attached to an IV pole. On [DATE], EMS B was stuck by the used sharps when she grabbed the IV pole to utilize during CPR. This failure could place residents and staff at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for one (Resident #1) of 10 residents reviewed for changes in condition. The facility failed to notify the responsible party (RP) for Resident #1 when he developed small pleural effusion requiring antibiotic therapy. These failures could place residents at risk for a decline in health, for family members not knowing the health status of the resident, being informed of and participating in care decisions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and other officials including to the State Survey Agency in accordance with State law through established procedures for 2 of 10 residents (Residents #2 and #3) reviewed for reporting allegations of abuse. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 residents (Resident #32) reviewed for enteral feeding. The facility failed to ensure LVN C mixed crushed medications with water and administered one medication at a time when giving medications to Resident #32 through her G-tube (a tube inserted through the wall of the abdomen directly into the stomach which allows the delivery of nutrition, fluids, and medications directly into the stomach). The facility failed to ensure LVN C administered Resident #32's G-tube medications by gravity, and instead she pushed the medications using the plunger of the syringe. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 6 residents observed for oxygen management. (Resident #76) The facility failed to keep the oxygen concentrator (machine that takes air from your surrounding and extract oxygen and filter it into purified oxygen to breath) filter clean for Resident #76 and humidifier bottle (oxygen can be drying to your nose so some patients use a humidifier bottle to moisten the oxygen you breath) filled with water. These failures could place residents at risk of a significant reduction in the quality of oxygen being delivered, inadequate oxygen support, and decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate administering of medications for 2 of 18 residents reviewed for pharmaceutical services. (Residents #2 and #19) The facility failed to ensure medication was not left at bedside for Resident #2. The facility failed to administer midodrine HCL prn as ordered on 01/02/25 and 01/06/25 when Resident #19's blood pressure was below prescribed parameters. These failures could place the residents at risk of not receiving the appropriate medications and services to maintain their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided the therapeutic diets as prescribed by the attending physician for 1 of 18 residents (Residents #21) reviewed for therapeutic diets food and nutrition services. The facility failed to ensure Resident #21 received a CC (control carbohydrate) diet (diet to help manage blood sugar) with the breakfast meals on 01/07/25 and 01/08/25 as ordered by physician. This failure could place residents with diet needs at risk for an increase in blood sugar level and potential decline in health.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, which includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 2 (Resident #1 and Resident #2) of 10 residents reviewed for involuntary seclusion. The facility failed to ensure CNA A did not place gloves in the Resident #1 and Resident #2 door to keep Resident #2 from wandering outside her room on 06/21/2024. The non-compliance was identified as past non-compliance. The noncompliance began on 06/21/2024 and ended on 06/21/2024. The facility had corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or neglect resulting in serious bodily injury, to the State Survey Agency, for 2 of 10 residents (Resident #1, Resident #2) reviewed for reporting allegations of abuse. The facility failed to report an allegation of abuse (involuntary seclusion) to the State Agency within 2 hours when it was reported on 06/21/2024 that Resident #1 and Resident #2 was involuntary secluded in their room by CNA A. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN A documented Resident #1's change of condition, physician notification, and transport to hospital on [DATE]. This failure could place residents at risk for delayed care and appropriate interventions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 14 residents (Resident #1) reviewed for resident rights. CNA A failed to provide privacy to Resident #1 when providing incontinent care on 02/06/24. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 14 residents (Resident #1) reviewed for infection control. CNA A did not wash or sanitize her hands or change gloves while performing incontinent care for Resident #1. CNA B entered Resident #1's room wearing gloves she had previously handled trash with and did not wash or sanitize her hands or change gloves. These failures could place residents at risk of exposure to communicable diseases and infections.

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 kitchen sanitation. The facility failed to ensure the dish machine reached 120 degrees Fahrenheit. The facility failed to ensure bulk foods were stored in a manner to prevent contamination. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS accurate direct care staffing information based on payroll and other verifiable and auditable data for 2 of 3 quarters reviewed. (Quarter 2 (January 1 through March 31) and Quarter 3 2023 (April 1 through June 1)). The facility failed to submit accurate RN coverage for 01/08/23, 1/27/2023, 03/11/23, 04/01/23, 05/07/23, and 05/13/23. This failure could place residents at risk for personal needs not being identified and met.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: The facility failed to ensure two of six gas burners, on the stove, lit automatically, when the knob was turned (front and back middle burners). The facility failed to ensure the dish machine reached 120 degrees Fahrenheit. These failures could place residents at risk of foodborne illnesses and injury.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 6 of 12 months (October 2022 through October 2023) and failed to ensure the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or less residents for 4 of 12 months (October 2022 through October 2023) reviewed for RN coverage. The facility did not have the required eight consecutive hours of RN coverage for 1 day in March 2023, 1 day in April 2023, 2 days in May 2023, 1 day in June 2023, 1 day in July 2023 and 2 days in August 2023. The facility DON served as a charge nurse in March 2023 with an average census of 89, in April 2023 with an average census of 92, in May 2023 with an average census of 94, and in August 2023 with an average census of 90. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents did not receive medications without an appropriate indication for use for 4 of 5 residents reviewed for unnecessary drugs. (Residents #26, #37, #42, and #74) The facility failed to prevent Residents #26, #37, #42, and #74 from receiving a medication without an appropriate prescribed indication for use. This failure placed the resident at risk of complications related to receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by not screening or testing 3 of 3 newly hired staff, who were reviewed for tuberculosis immunizations. (LVN A, CNA B and CNA C). The facility did not screen or administer a tuberculosis test for 3 newly hired staff. These findings could place the residents at risk of exposure to communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to refer residents to the pre-admission screening and resident review (PASARR) program under Medicaid for 1 of 5 residents reviewed for PASRR. (Resident #42) The facility did not submit a new PASRR Screening and refer Resident #42 with newly evident mental disorder. This failure could place residents with mental illness at risk for not receiving appropriate services and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 23 residents reviewed for ADL care. (Resident #56) The facility did not ensure Resident #56's fingernails were trimmed. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 23 residents reviewed for range of motion. (Resident #56) The facility failed to maintain Resident #56's contractures of the right hand. The resident did not have a hand splint in place 2 hours a day to maintain ROM and prevent a decline. This failure could place the residents at risk for not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate residents' food preferences for 1 of 20 (Resident #299) resident reviewed for food preferences. The facility failed to ensure Resident #299 received her preference of a chicken salad sandwich with chips during the lunch meal on 12/10/23. This failure could place residents with food preferences at risk for a decrease in resident choices and diminished interest in meals.

Inspectors wroteBased on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis for 1 of 1 social worker reviewed for social services. The facility failed to employ a full-time social worker since 09/15/2023. This failure could affect any residents in need of social services and place them at risk of psycho-social decline and poor-quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS quarterly assessment was electronically transmitted to the CMS System for 1 of 21 residents records reviewed for MDS assessments. (Residents #82) The facility did not ensure the quarterly MDS assessment was completed and successfully electronically transmitted and accepted as required for Resident #82. This failure could place residents at risk of not having their assessments transmitted and accepted in a timely manner.

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 of 7 residents (Residents #1) reviewed for pharmacy services. The facility failed to keep a record of receipt for all received controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled. The facility failed to ensure staff followed the facility's procedure to have two licensed nurses receive Resident #1's delivered Hydrocodone (controlled drugs) from pharmacy delivery personnel, resulting in a drug diversion of 60 tablets of Resident #1's Hydrocodone. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' right to be free from abuse and neglect for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to provide incontinent care to Resident #1 for more than 8 hours on 09/24/23. Resident #1 sustained excoriation (injury to the skin), swollen labia, and a blister to her peri-area (delicate portion of skin between your genitals and anus). An Immediate Jeopardy (IJ) situation was identified on 09/28/23 at 1:43 p.m. While the IJ was removed on 09/29/23, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

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 received the necessary services to maintain personal hygiene for 1 of 10 residents (Resident #1) reviewed for ADL care. The facility failed to provide incontinent care to Resident #1 for more than 8 hours on 09/24/23. Resident #1 sustained excoriation (injury to the skin), swollen labia, and a blister to her peri-area (delicate portion of skin between your genitals and anus). An Immediate Jeopardy (IJ) situation was identified on 09/28/23 at 1:43 p.m. While the IJ was removed on 09/29/23, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record for 1 of 2 discharged residents (Resident #2) reviewed for discharge requirements. The facility refused to re-admit Resident #2 from a behavioral unit. Resident #2's clinical record had no physician documentation to address why the resident was being discharged , what needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. This failure could place residents at risk for inappropriate discharge from the facility and cause psychological harm.