Sabine Heights Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two (Resident #1 and Resident #2) of two residents reviewed for quality of care. The facility failed to transfer Resident #1 safely and appropriately, leaving her armpit, arm, and chest area bruised. The facility failed to transfer Resident #2 safely when they failed to ensure the gait belt was not too loose to use appropriately and lifted the resident mostly under her armpits when transferring her from the bed to the wheelchair on 05/01/26. This failure could affect the residents by placing the residents at risk for discomfort, pain, and/or injury.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen (Kitchen #1) reviewed for kitchen sanitation. The facility failed to ensure the current menu for 01/11/2026- 01/17/2026 was posted for residents to see. The facility failed to ensure the wall above the food in the kitchen prep area was not coated with grey dust and debris. The facility failed to ensure the storage food rack in the kitchen food prep area was free from visible dust, yellow and brown sticky colored residue. The facility failed to ensure [NAME] A followed the facility recipe for stewed okra/ tomatoes. These failures could place residents at risk for cross contamination and food-borne illness. Findings Include: During an observation on 01/13/2026 at 9:45 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 16 residents reviewed for notification of changes. (Resident #5) The facility did not consult with Resident #5's physician about the pattern of low blood pressure over consecutive days and of the blood pressure medication being held for 15 of 31 opportunities in December 2025 or 3 of 6 opportunities for January 2026. This failure could place residents at risk for complications due to delayed or failed physician intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure the hired Social Worker had the required qualifications for 1 of 1 facility reviewed for social worker qualifications. The social worker hired on 10/06/25, as a full-time social worker was not licensed by the Texas State Board of Social Worker Examiners. This failure could place all residents at risk for unmet social services and psychosocial needs.

Inspectors wroteBased on interviews and record review, the facility failed to provide required Quality Assurance Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 9 of 18 (LVN E, LVN F, LVN G, LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N) staff sampled for licensure and training. The facility failed to ensure that LVN E, LVN F, LVN G, LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N had completed their mandatory QAPI training. This failure could place residents at risk of being care for by untrained staff.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 5 residents (Resident #14) reviewed for reporting abuse and neglect. CNA F failed to report Resident #14's complaint of neglect (Resident #14 told LVN E that she was having shortness of breath and requested a breathing treatment. LVN E allegedly told her she could breathe because she just talked on the phone) to the Administrator on 12/25/2025 at 4:00 p.m. when the incident occurred. This failure could potentially result in residents' complaints or incidents of abuse not being reported to the Administrator.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition for 1 of 16 residents (Resident #34) reviewed for comprehensive assessments and timing. The facility failed to ensure an MDS Significant change Assessment for Resident #34 was completed within 14 days after hospice admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 4 residents (Resident #14) reviewed for care plans. The facility failed to develop and implement a comprehensive care plan for significant change in condition on 12/04/2025 for Resident #14 when she was placed on hospice. This failure could place residents at risk of receiving inadequate care and services.

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 necessary services to maintain good grooming and personal hygiene for 1 (Resident #11) of 16 residents reviewed for activities of daily living. The facility failed to remove unwanted facial hair from Resident #11's chin area observed on 01/05/2026. This failure placed residents at risk for psychological embarrassment, sadness, and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 30 opportunities, resulting in a 6.67% percent medication error involving 2 of 5 residents reviewed for medication pass. (Resident #54 and Resident #58)LVN D administered an incorrect dose of bupropion HCL ER (used to treat depression) to Resident #54 on 01/06/2026 during medication pass. LVN D administered carvedilol 3.125 mg tablet (used to treat high blood pressure) to Resident #58 when the heart rate was outside the parameters ordered by the physician. These failures could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life.1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 2 medication carts reviewed for storage of medications and biologicals. (Hall 300 Medication cart and Hall 400 Medication cart) The facility failed to ensure Hall 300 medication cart was free of loose pills at the bottom of the medication cart drawer. The facility failed to ensure Hall 400 medication cart was free of loose pills at the bottom of the medication cart drawer. These failures could place residents at risk of not receiving prescribed drugs. During an observation and interview on [DATE] at 9:00 a.m., an inspection of Hall 300 medication cart with LVN A was discovered 7 whole miscellaneous pills and 6 broken pills loose in drawer 2 of the medication cart. [...]

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 2 of 4 residents (Resident# 4 and Resident # 6) observed for Enhanced barrier precautions. The facility failed to ensure the enhanced barrier precaution sign was on Resident #4's and Resident #6's door. This failure could place residents and staff at risk for cross-contamination and development of infections.

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 the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for comprehensive person-centered care plans. Resident #1 did not have a care plan completed for her diagnosis of generalized anxiety. Resident #1 did not have a care plan completed after she was prescribed Buspirone/Buspar (anti-anxiety medication) on 10/16/25 for anxiety. This failure could place residents at risk for not receiving proper care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 7 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on 09/14/2025 and was located by facility staff approximately 50 feet off facility premises in a tall grassy area with rocks, uneven ground, and cut trees. An IJ was identified on 09/14/2025. The IJ template was provided to the facility on [DATE] at 4:10 p.m. While the IJ was removed on 09/19/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on Elopement. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (the process of receiving and interpreting prescriber's orders and to provide procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs) to meet the needs of each resident for one (Resident #2) of four residents reviewed for pharmaceutical services. The facility failed to ensure Resident #2's hospital discharged medication regimen was accurately reviewed and implemented. Resident #2 was readmitted to the hospital with respiratory failure and COPD. The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 19 residents reviewed for significant medication errors. (Resident #2)The facility must ensure that its residents are free of any significant medication errors. Resident #2 received multiple doses of medications that were not prescribed to her to include 2 blood thinners and blood pressure medications. Also, Resident #2 did not receive prescribed breathing treatments and anti-inflammatory medications and was re-hospitalized with COPD.The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in accordance with currently accepted professional principles for 1 of 3 medication carts (300 hall) reviewed for storage of medication and biologicals. The facility failed to ensure 4 tablets of Ondansetron 8mg (medication used for nausea and vomiting) expired 10/31/24, had been expired for 322 days, were removed from use. The facility failed to ensure 5 tablets of Clonidine 0.1mg (medication used for high blood pressure) expired 07/31/24, had been expired for 414 days, were removed from use. These failures could place residents at risk of adverse reactions to medications, misappropriation of medications, and not receiving therapeutic effects of medication.

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 infection control for 3 of 4 residents (Resident #3, Resident #4, Resident #5), and 2 of 2 therapists, (PT #1 and OT #2.) The facility failed ensure PT #1 and OT #1 used hygiene and wipe down therapy equipment between Resident's use. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 7 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 was free from resident to resident sexual abuse when Resident #2 touched her vaginal area inappropriately on 08/14/2025 and was witnessed by Resident #3. The noncompliance was identified as PNC. The IJ began on 08/14/2025 and ended on 08/14/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of care, and further abuse.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for 8 at least consecutive hours 7 days a week for 1 of 4 quarters of 2023 (Quarter 1 - October 01, 2023, through December 31, 2023) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 10/07/2023, 11/11/2023, 11/12/23, 11/25/23, 12/03/23, 12/16/23, and 12/17/2023. This failure could place residents at risk of lack of nursing oversight and a higher level of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, residents who use psychotropic drugs, behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 21 residents (Resident #39); and PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 2 of 21 residents (Residents #55 and #61) all reviewed for unnecessary medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 3 of 9 residents reviewed for accurate medical records. (Residents #15, #55, and #61) The facility did not ensure staff documented on the MARs medications were administered to Residents #15, #55, and #61. 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 that residents who needed respiratory care, including tracheotomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents'' goals and preferences for 1 of 1 resident reviewed for tracheotomy care (Resident #284). The facility failed to ensure LVN A followed proper technique during tracheostomy care and suctioning for Resident #284. (Tracheostomy is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for breathing. The inner cannula fits inside the trach tube and acts as a liner that can be removed and cleaned to help prevent the build-up of mucus inside the trach tube. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including 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 10 residents (Resident #1) reviewed for pharmacy services. The facility failed to transcribe Resident #1's discharge orders dated 04/08/24 and failed to follow-up to ensure Resident #1's hospital discharge orders were implemented to include her Rivaroxaban (Xarelto-used to prevent blood clots). Resident #1 was not administered Rivaroxaban (Xarelto) for 38 days. Resident #1 was admitted to hospital on [DATE] and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medication errors. The facility failed to administer Resident #1's Rivaroxaban (Xarelto-used to prevent blood clots) for 38 days (04/09/24 through 05/17/24). Resident #1's hospital discharge orders were not implemented to include her Rivaroxaban (Xarelto). Resident #1 was admitted to hospital on [DATE] and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure. An IJ was identified on 06/14/24 at 12:05 p.m. The IJ template was provided to the facility on [DATE] at 12:20 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); for 1 of 4 residents reviewed for notification. (Resident #1) The facility failed to consult with Resident #1's physician, when Resident #1's HIV (a virus that attacks the human immune system) medication Triumeq (a medication used to treat HIV; discontinuation or interruption of antiretroviral therapy (ART) may result in viral rebound, immune decompensation, and/or clinical progression) was not available for administration in August 2023 for 11 doses and September 2023 for 3 doses. An Immediate Jeopardy (IJ) situation was identified on 10/02/23 at 4:24 p.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 4 residents reviewed for significant medication errors. (Resident #1) The facility failed to ensure Resident #1's HIV ([human immunodeficiency virus] a virus that attacks the human immune system) medication was available for administration in August 2023 for 11 doses and September 2023 for 3 doses. Resident #1 had a diagnosis of HIV. An Immediate Jeopardy (IJ) situation was identified on 10/02/23 at 4:24 p.m. While the IJ was removed on 10/03/23 at 5:40 p.m., the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy at a scope of a pattern 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 the residents promptly received mail for 2 of 6 residents reviewed for resident rights. (Residents # 10 and #23). The facility did not implement a system for delivering mail on Saturdays; resulting in Residents #10 and #21 not receiving mail delivered on Saturdays until Monday. This failure could place the residents at risk of a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received services with reasonable accommodation of the resident's needs and preferences for 1 of 19 (Resident #278) residents reviewed for call light placement. Resident #278, who required extensive assistance of 2 to transfer, did not have her call light in reach. This failure could place the residents at risk for not receiving the appropriate care and services to maintain their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations from PASARR evaluation were incorporated for 1 of 7 residents reviewed for coordination of PASRR services. (Resident #38) Facility failed to provide specialized services for PASRR positive residents as agreed to during Resident #38's IDT meeting or provide information the services were no longer needed by the required timeframe. This failure could place the residents with intellectual and developmental disabilities at risk of not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the minimum healthcare information necessary to properly care for a resident for 1 of 4 residents reviewed for baseline care plan. (Resident #73) The facility did not address Resident #73's PASRR in the baseline care plan. This failure could place newly admitted residents at risk of not having their individual, medical, functional, and psychosocial needs identified, appropriately addressed, and could cause physical or psychosocial decline in health.

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 19 residents reviewed for ADL care. (Resident #61) The facility did not ensure Resident #61'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 respiratory care was provided according to professional standards of practice for 1 of 19 residents reviewed for respiratory care and services. (Resident #9) The facility did not provide Resident #9's oxygen with a clean filter. The filter was covered with a thick layer of white powdery substance. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life.

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 9 of 9 months reviewed (January 2023 through September 2023) and failed to ensure the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. * The facility did not have RN coverage for Saturdays (SA) and Sundays (SU) in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, and September 2023. * The facility did not have RN coverage for 8 consecutive hours in April 2023, May 2023, and August 2023. * The DON served as a CN in May 2023, June 2023, and August 2023 with census of greater than 60 residents. [...]

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 1 of 5 residents reviewed for unnecessary medications. (Resident #71) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #71's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 of 5 residents reviewed for PRN psychotropic medications. (Resident #22) The facility did not have an order to extend a prn order beyond 14 days, have physician documentation for rationale, or have documentation to indicate the duration for the PRN order for Resident #22. This failure could place residents at risk of decreased quality of life due to improper use of psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 1 of 4 medication carts observed and a personal item was stored on 1 of 1 medication cart. (Hall 400 medication cart and the facility treatment cart) in that: *LVN B was not aware of loose pills and scattered debris in the bottom of the Hall 400 medication cart drawers. *LVN E left a personal cup in the bottom drawer of the medication cart. These failures could place residents at risk of misappropriation of drugs, not receiving prescribed drugs or contaminated medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the most recent survey of the facility posted in a place readily available to resident's, family members, and/or legal representatives for 6 of 6 residents reviewed for survey results. (Residents #3, #10, #11, #23, #33, and #43) The facility did not have the most recent survey results available. This failure could place residents, family members, and legal representatives at risk of not being informed of survey results.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the posted daily staffing data was retained for 18 of 18 months reviewed for staffing postings. The facility did not have 18 months of staffing postings data. This failure could place residents, families, and visitors at risk of not having access to information regarding staffing data and facility census.