Oakmont Healthcare and Rehabilitation of Humble

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident # 4) of 5 residents reviewed for quality of care. -Resident #4's right hand splint was not put on in the AM of 06/11/26. This failure could place residents at risk for a decline in movement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for residents, staff, and the public, for 2 of 21 resident rooms (Resident #39 and #28) reviewed for physical environment. The facility failed to maintain clean privacy curtains for Resident #39 and clean bed linen for an unoccupied bed in Resident #28's room. This failure could lead to residents experiencing a diminished quality of life.

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 19%, based on 5 errors out of 26 opportunities, which involved 2 of 6 residents (Resident #26 and #28) and 2 of 4 staff (LVN J and LVN D) observed during medication administration reviewed for medication errors. LVN J administered insulin to Resident #26 at the incorrect time according to the facility MAR.LVN D failed to flush with water between medications during g-tube administration for Resident #28. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications.

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 resident rights set forth to attain or maintain the residents highest practicable physical, mental, and psychosocial needs and well-being for 1 of 14 (Resident #69) residents. The facility failed to ensure that Resident #69's care plan documented interventions for hand contractures. This failure could result in residents being at risk and not receiving proper care.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision for 1 (Residents #71) of five residents reviewed for accidents and hazards. The facility failed to ensure that Resident #71's face was not pressed against the nightstand while she was getting incontinent care. This failure could place residents at risk of injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of three (Resident #6) residents reviewed for respiratory care. The facility failed to ensure Resident #6's oxygen was administered at the prescribed setting. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.

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 (Resident #1) of 5 residents reviewed for range of motion. The facility failed to ensure Resident #1's leg and hand splint was offered and applied according to MD orders. This failure could result in worsening of contractures and ADL decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 5 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #1's fall mat was in place on 1/28/26 according to the care plan. The facility failed to ensure Resident #1 was changed with 2 people instead of 1 on 1/28/26 as indicated in the care plan. The facility failed to check Resident #1's brief every 2 hours on 1/28/26 as indicated in the care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents have the right to a safe, clean comfortable, and home like environment, including but not limited to receiving treatment and supports for daily living safely for residents, staff and the public for 3 of 4 days (09/15/2025, 09/16/2025, 09/18/2025) for 2 (Resident #2 and Resident #7) of 21 residents. The facility failed to maintain a clean and sanitary environment in resident rooms, specifically regarding the cleanliness of the floors. This failure could place risk for the residents by slipping, tripping, pest attraction, or infection control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 (Resident# 1) of 6 residents reviewed for activities of daily living in that: The facility failed to provide mouth care to Resident #1 on 6/24/2025. This failure placed residents who need assistance with ADL at risk for psychological embarrassment, sadness, and decrease in quality of life. Record review of Resident #1's face sheet dated 07/10/25 revealed a [AGE] year-old female who was admitted to the facility initially on 02/25/2021 and readmitted on [DATE]. The resident's diagnoses included the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parental fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #1) reviewed for parental fluids. The facility failed to ensure Resident #1's right arm PICC line (a thin, flexible tube that is inserted into a vein and threaded into a larger vein near the heart for long-term intravenous treatments) dressing was changed weekly (the dressing was dated 01/06/2025 upon observation on 01/16/2025) as ordered by her physician. This failure placed residents with intravenous (within the vein) lines at risk of developing infection.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 3 of 6 residents (Resident #43, Resident #45, and Resident #7) reviewed for pressure ulcers. - The facility failed to provide daily wound care for Resident #43 on 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24, resulting in worsening of his L Heel, R Heel, R Distal (closest to foot) Leg, R Proximal (furthest away from foot) Leg, L Ischium (buttock), and R Ischium (buttock) pressure ulcers. - The facility failed to receive Resident #43's biopsy/culture results for his R heel that was performed 9/30/24, until 10/24/24. [...]

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 for the facility's only kitchen reviewed for dietary services in that: -The facility failed to ensure that drink items in the dry storage area were not expired. -The facility failed to ensure that the refrigerator temperatures were logged daily. These findings could place residents at risk for food contamination and/ or food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for 3 of 4 residents (Resident #14, #26, and #36) reviewed for resident assessment. The facility failed to ensure Resident #14, #26, and #36's PASRR Level I screening reflected their mental illness diagnosis. These failures could place residents at risk of not receiving specialized services for their mental illness.

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 8 residents (Resident #3) reviewed for dental services. The facility failed to ensure Resident #3 was referred to the dentist after she complained of tooth pain. This failure could place residents at risk of pain and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of five residents reviewed for accidents hazards and supervision, in that: -Resident #2 fell from lift, sustained a head abrasion and L foot fracture during a Hoyer lift transfer (a device designed to assist caregivers in safely transferring patients or individuals with limited mobility) when CNA K operated the Hoyer lift by herself. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 1/2/24 and ended on 1/3/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of injury and hospitalizations.

Inspectors wroteBased on observation, 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 for 1 (Resident #1) of 5 residents viewed for infection control. -LVN A did not wear appropriate PPE when providing peg-tube care (PEG tubes allow you to receive nutrition through your stomach) to Resident #1 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes). This failure could place residents at risk of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 3 of 5 residents (Residents #1, #2, #3) reviewed for pests, in that: -Resident #1 had multiple gnats flying around his face and room. -Resident #2 had multiple gnats flying around her bed and room. - Resident #3 had a fly on her walker in her room. This deficient practice could place residents at risk of residing in an environment with pests.

Inspectors wroteBased on observation, interview and record review, the facility failed to consult with 1 of 16 residents (Resident #8) representatives when there was a significant change in the resident's physical status and a need to alter treatment significantly, in that: - The facility failed to notify Resident #8 family of a PEG tube was deemed non-functional for over 5 months resulting in multiple infections at the site of the G-tube and the resident was ultimately hospitalized when Resident #8's tube became dislodged and caused a partial bowel obstruction. - Resident #8 experienced a decline in ADLs as evidenced by downgrade from Regular heart healthy pureed diet to enteral feeds after tube replacement post- partial bowel obstruction. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 2 of 5 residents (CR #19 and Resident #317) reviewed for professional standards. - The facility failed to ensure RN C administered Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - The facility failed to ensure RN C sent CR #19 through immediate emergency transport after being diagnoses with critical vitals. - The facility failed to ensure RN C administered Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. An IJ was identified on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice provided to 3 of 16 residents, (CR #19, Resident #1 and Resident #317), reviewed for quality of Care. - The facility failed to ensure RN C administered Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - The facility failed to ensure RN C sent CR #19 through immediate emergency transport after being diagnoses with critical vitals. - The facility failed to ensure RN C administered Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. -The facility failed to reinstate Resident #1's Metformin after readmission to the facility. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. [...]

Inspectors wroteBased on observation, interview and record review, for 1 of 6 residents (Resident #8) reviewed for enteral nutrition, the facility failed to ensure whoever was able to eat enough was not fed by enteral methods unless the resident's clinical condition demonstrated that the enteral feeding was clinically indicated and consented to by the resident, in that: - Resident #8 had a PEG tube deemed non-functional for over 5 months without enteral feeds or water flushes. - Resident #8 experienced multiple episodes of infections at her PEG tube site. - The NP convinced Resident #8's RP to not remove PEG tube in case it needed to be used for emergency enteral feedings or medications. She did not communicate resident's complications related to PEG tube or that it was non-functional. - Resident #8 was found on 08/16/2023 with PEG tube pulled out with tip broken off and was hospitalized as a result. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 6 staff ( RN C) and 2 of 5 residents ( CR #19 and Resident #317) reviewed for nursing competency. - RN C failed to administer Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - RN C failed to send CR #19 through 911 emergency transport after being diagnosed with critical vitals. - RN C failed to administer Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. An IJ was identified on [DATE] at 09:00 AM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 12 residents (Resident #62, Resident #217 and Resident #317) reviewed for pain management. - The facility failed to acquire, dispense, and timely administer pain medications and failed to assess Resident #317's pain resulting in pain of 10 out of 10. - The facility failed to assess and document Resident #62 pain accurately or at all. - The facility failed to assess and document Resident #217's pain. An IJ was identified on 09/06/23. The IJ template was provided to the facility on [DATE] at 04:20 PM. [...]

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 4 of 10 residents (Resident #24, Resident #54, Resident #61 and Resident #317) reviewed for pharmaceutical services. - The facility failed to acquire, dispense, and timely administer medications to Resident #317 upon admission resulting in pain of 10 out of 10. An IJ was identified on 09/06/23. While the IJ was removed on 09/11/23 at 1:57 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents, (Resident #217 and Resident #8), in that: - Resident #217 was on scheduled pain medication but did not have a care plan for pain. - Resident #8 had a PEG tube in place but was not care planned for pain or PEG tube use. These failures could place residents at risk of not receiving adequate medical care in a timely manner.

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 39 % based on 15 errors out of 38opportunities, which involved 5 of 7 residents (Resident #6, Resident #24, Resident #36, Resident #54 and Resident #61 ) reviewed for medication errors. - LVN A failed to administer medications as ordered to Resident # 36 by attempting to administer Insulin outside of ordered parameters. - LVN A failed to administer medications as ordered to Resident #6 by Crushing Potassium Chloride ER, a medication that should not be crushed, and failing to flush between medications administered via G-tube(a tube administered through the belly that brings nutrition directly to the stomach). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for 1 of 12 rooms (room [ROOM NUMBER]) reviewed for safe and sanitary environment for residents. - The facility failed to clean fecal matter off the floor of a resident room [ROOM NUMBER]. This could place the facility at risk of decreased quality of like due to the lack of a well-kept environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that any irregularities noted by the pharmacist and documented on a separate written report to the physician was reviewed by the physician and additional orders obtained for services to meet the needs of 1 (Resident #1) of 5 residents reviewed for pharmacist review, in that: -The facility did not follow up on Resident #1's Levemir dosage increase by the consultant pharmacist on 8/30/2023. This failure could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 5 residents (Resident #10 and Resident #35) reviewed for unnecessary Psychotropic drugs. - The facility failed to ensure Resident #10 did not receive a psychotropic medication, Sertraline (an anti-depressant) since 11/09/22 to 09/12/23 without a diagnosis of depression - The facility failed to ensure Resident #35 did not receive an unnecessary extra dose (175 mg instead of 75 mg) of a psychotropic medication Seroquel (Quetiapine ) an anti-psychotic. These failures could place residents at risk for increased side effects as well as decline in physical and psychosocial health. Findings Included: [...]

Inspectors wroteBased upon observation and interview, drugs and biologicals used in the facility must be secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts ( Station 1 Medication Cart) reviewed for drug labeling and storage. - The facility failed to ensure the Station 1 Medication Aide Cart was locked when not in use. This failure could place residents at risk of adverse medication reactions and drug diversions. Findings Included: An observation starting on 09/16/23 at 06:20 AM revealed, the Station 1 Medication Aide Cart was unlocked with RN C sitting on at the nursing station. The cart remained unlocked until 06:32 AM when the surveyor notified RN C. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 5 residents (Resident #62) whose records were reviewed for accuracy and completeness. - LVN A failed to accurately document medication administration to Resident #62 by documenting a pain score she did not collect. This failure could place residents at risk of inaccurate information resulting in inappropriate care. Findings Included: Record review of Resident #62's Face Sheet dated 09/11/23 revealed, a [AGE] year-old man who admitted to the facility on [DATE] with diagnoses which included: history of falling, unspecified dementia, hypertension, muscle weakness and cognitive communication deficit. [...]