Patriot Heights Health Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's fall mat was utilized per the comprehensive care plan. This failure could place residents at risk for accidents and injuries related to risk of falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 1 of 5 Residents (Resident #2) reviewed for medication storage:The facility failed to ensure Resident #2 did not have a container of antifungal powder at the bedside. This deficient practice could affect residents who received medications in the facility and place them at risk for not receiving the correct medications, medication misuse or drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had the right to be free from abuse and neglect for 2 of 6 residents (Resident #1 and Resident #2) reviewed for resident abuse. The facility failed to ensure a safe environment free from sexual abuse when Resident #1, who had a history of alleged sexual behaviors, placed his mouth on Resident #2's breast on 10/28/2025 at 04:15 p.m. The noncompliance was identified as past non-compliance IJ. The IJ began on 10/28/2025 and ended on 10/29/2025. The facility had corrected the noncompliance before the investigation began, 10/29/2025 at 12:30 p.m. This failure could place residents at risk of physical harm, pain, mental anguish, and/or emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 6 residents (Resident #19, Resident #51, and Resident #55) who were reviewed for resident assessments. 1. The facility failed to document Resident #19's use of pain medication on the MDS assessment.2. The facility failed to document Resident #51's use of hypoglycemic medication on the MDS assessment.3. The facility failed to document Resident #55's use of antiplatelet medication on MDS assessment. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 (West Hall) of 8 shower rooms observed for environment. The facility failed to ensure resident shower room on the [NAME] Hall was clean, safe, and in good repair. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations misappropriation were reported to the State Survey Agency no later than 24 hours after misappropriation was alleged for 1 of 8 residents (Resident #1) reviewed for misappropriation of resident property. The facility failed to report to HHSC when Resident #1's lost gold wedding ring, which was reported missing on [DATE], a replacement was provided on 04-09-2025 the facility did not report to HHSC within 24 hours. This failure could place residents at risk of misappropriation of money, possessions, and feelings of loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (treatment cart) reviewed for drug security and 2 of 13 residents (Resident #16 and Resident #41) reviewed for medications at the bedside. 1. Facility treatment cart was left unattended and unlocked at the North-hall on [DATE] at 9:52 a.m. 2. Resident #16's Triad Hydrophilic wound dressing cream was left unattended and unsecured on the nightstand at the resident's bedside. 3. South-hall nursing cart had Resident #41's insulin pen with open date [DATE], but DON said Novolog insulin pen should have been discarded after 28 days once it was opened. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 13 Residents (Resident #4) whose MDS records were reviewed for accuracy. The facility failed to ensure Resident #4's quarterly MDS assessment, dated 06/17/2024, accurately reflected the resident had a significant weight loss. This failure could place residents at risk for inadequate care due to inaccurate assessments.

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, for 1 of 2 residents (Residents #11) reviewed for respiratory treatment in that: Resident #11's nebulizing mask and tubing were observed on 07/28/2024, and it was covered in a plastic bag but dated on 05/12/2024. This failure could affect residents who received nebulizing treatment by placing them at risk for respiratory infections.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #1) reviewed for medication administration. During medication administration observation on 07/30/2024, MA hold Resident #1's Metoprolol Tartrate 25 mg because of low blood pressure (118/50), but the MA did not notify holding the medication to the charge nurse, LVN D. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 13 residents reviewed, in that: Resident #1's personal refrigerator located in his room was observed on 07/28/2024, and there was a small plastic container inside the refrigerator with olives, but no date on the plastic container.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 13 residents reviewed for accuracy and completeness of clinical records. LVN D did not document Resident #1's refusal of wound care on 07/04/2024 to the resident's treatment administration record. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical record.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 5 residents (Resident #2 and #3) reviewed for respiratory care. 1. The facility failed to ensure Resident #2's oxygen tubing and concentrator humidifier with connected tubing was not on the floor. 2. The facility failed to ensure Resident #3's oxygen tubing was not on the floor. These deficient practices could place residents at risk of cross contamination, infections, receiving incorrect or inadequate oxygen support and could result in a decline in health.

Inspectors wroteBased on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was an accident with potential for requiring physician intervention for 1 of 6 Residents (Resident #1) whose records were reviewed for accidents. LVN A failed to notify Resident #1's physician and representative when he had a fall on 9/18/23 which resulted in a delay of care. The facility failed to consult the physician when the mobile x-ray did not arrive timely to take the x-ray resulting in Resident #1 waiting 15 1/2 hours for his x-ray to be taken. Resident #1 was hospitalized on [DATE], was diagnosed with a right hip fracture and admitted for surgery. The noncompliance was identified as past noncompliance Immediate Jeopardy (IJ). The noncompliance began on 9/18/23 and ended on 11/30/23. [...]

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 resident's choices for 1 of 6 Residents (Resident #1) reviewed for treatments and services. LVN A failed to ensure Resident #1 received appropriate assessments and interventions when he had a fall on 9/18/2023, which she did not report as a fall to an oncoming nurse, DON or Administrator. The facility failed to consult the physician when the mobile x-ray did not arrive timely to take the x-ray resulting in Resident #1 waiting 15 1/2 hours for his x-ray to be taken. Resident #1 was hospitalized the following day on 9/19/2023 and diagnosed with a right hip fracture. The noncompliance was identified as past noncompliance Immediate Jeopardy (IJ). [...]

Inspectors wroteBased on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 of 7 residents (Resident #2) reviewed for transfer/discharge. The facility failed to readmit Resident #2 after an acute care hospital stay resulting in Resident #2 not being permitted to stay in the facility pending placement or appeal. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurate for two of five residents (Residents #1 and #2) reviewed for accuracy of records, in that: 1. Resident #1's physician orders for [DATE] had both full code and DNR listed as the resident's code status. 2. Resident #2's consent for the anti-depressant medication Sertraline was placed in Resident #1's EMR. These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 5 residents (Resident #1) reviewed for unnecessary medication in that: Resident #1 received two types of blood thinners from 9/22/23 to 9/27/23. This failure could affect residents who receive blood thinner medications and place them at risk for adverse drug reaction and being over-medicated.

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 5 residents (Resident #1) reviewed for drug administration in that: Resident #1 did not receive his morning insulin dose on 10/1/23. This failure could affect residents who receive insulin and place them at risk for not receiving a therapeutic effect.

Inspectors wroteBased interview and record review the facility failed to immediately inform the resident's responsible party when there was a significant change in the resident's physical mental or psychological status for 1 of 1 resident (Resident #1) reviewed for notification of change of condition. The facility failed to notify Resident #1's responsible party when Resident #1 sustained a fall following major hip surgery. This failure placed residents at risk of not being aware of any changes in their conditions and could result in the decline of the residents' health and well-being.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for one resident (#1) out of 5 residents reviewed for accident hazards in that: Resident #1's bed was left in a high position following a recent fall with contradicted interventions stated in Resident #1's care plan. This deficient practice could affect residents and could result in injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 1 of 6 residents (Resident #28) reviewed for resident rights, in that: LVN A obtained a blood sugar check and administered an insulin injection to Resident #28 while the resident was in the dining room participating in an activity. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 1 resident reviewed for quality of care (Resident #202). The facility did not maintain physician orders and medical information needed to monitor Resident #202's cardiac pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm that stimulates the heart with electrical impulses to maintain or restore a normal heartbeat) parameters for proper functioning. This failure could place residents of risk for not receiving proper care and treatment.

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 2 residents (Resident #28) reviewed for infection control practices, in that: LVN A administered an insulin injection to Resident #28 in the dining room without performing hand hygiene or using gloves This failure could place residents at risk for infection, transmission for communicable diseases and or a decline in health

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 2 of 2 Residents (Residents #23 and #39) reviewed for transmitting assessments in that: 1. Resident #23's quarterly MDS assessment was not completed and transmitted within 14 days of completion. 2. Resident #39's quarterly MDS assessment was not completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted to the CMS system in a timely manner as required.