West Houston Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 6 of 10 residents (Residents #1, #2, #3, #5, #9, and #10) reviewed for resident rights. The facility failed to ensure Residents #1, #2, #3, #5, #9, and #10 had privacy curtains that were free of stains and other build-up. These failures could place residents at risk of injuries, cross-contamination, avoidable infections and a decrease in quality of life. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the status of 3 of 24 residents (Resident #3, Resident #35 and Resident #51) whose assessments were reviewed, in that: -Resident #3's stage 4 pressure ulcer was not documented on his latest Quarterly MDS dated [DATE].- Resident #35's dental condition and any related concerns were not documented in the most recent annual (dated 09/25/2025) and quarterly (03/18/2026) MDS assessments.- Resident #51's significant change MDS assessment did not reflect penile slit on 03/25/2026. This failure could place residents at risk because of their health conditions not reflected in their documentation and potentially not receiving the care and services deemed necessary due to inaccurate assessments. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident 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 describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 16 residents (Residents #51, #73 and #91) reviewed for comprehensive care plans.1. The facility failed to care plan Resident #51, Resident #73 and Resident #91 for leg straps.2. The facility failed to care plan Resident #51's penile slit and any related interventions. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care and in making appointments with 1 of 10 residents (Resident #35) reviewed for dental care. -The facility failed to assist the resident in making a follow-up dental appointment.-The facility failed to provide documentation of the extenuating circumstances that led to the delay in Resident #35 not having routine and follow-up dental appointments.-The facility failed to notify Resident #35's guardian of the dental recommendations. These failures could place residents at risk of oral complications, dental pain, and diminished quality of life. Record review of Resident #35's face sheet dated 04/08/2026 reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. [...]

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 4 residents (Resident #51) reviewed for incontinent care. 1. The facility failed to ensure Resident #51's indwelling catheter was secured and penile slit documented. Resident #51 had a slit on his penis measuring 3 cm length by 1.5 cm width on 04/08/2026. These failures could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 4 residents (Residents #27 and #48) reviewed for respiratory care.-The facility failed to ensure Resident #27's and Resident #48's oxygen humidifier bottle on the oxygen concentrator had enough water in the bottle to function properly. These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. Resident #27Record review of Resident #27's undated face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] and was readmitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 1 of 5 residents (Resident #56) reviewed for call lights. The facility failed to ensure Resident #56's call light was within reach. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life.

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 nutrition, grooming, and personal and oral hygiene for 1 (Resident #2) of 6 residents reviewed for activities of daily living. -The facility failed to groom Resident #2's face that was observed with long facial hairs on her chin. This failure placed resident at risk for embarrassment, depression, and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal pharyngeal ulcers for 1 (Resident #66) of six residents reviewed for gastrostomy feedings in that: -The facility failed to administer Resident #66 gastrostomy feedings at the rate ordered, 50 ml/hr. This failure placed resident at risk for not receiving their required daily nutritional intake placing the resident at risk for weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #62) of 6 residents observed for oxygen management. -The NF failed to dispose of an undated oxygen humidifier bottle from Resident #62's room that was at the bedside. This failure placed resident at risk for cross contamination, infections, and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review , the facility failed to provide pharmaceutical services including procedures that assure accurate acquiring, receiving, dispensing and administering of all drugs to meet the needs of each resident for 1 resident (Resident #43) of 9 residents reviewed for pharmacy services, in that, MA A did not administer Dorzolamide Hydrochloride Ophthalmic solution (eyedrops used to lower pressure inside the eye in people with open angle glaucoma or ocular hypertension) to Resident #43's lower eyelid for it to be absorbed for effectiveness. These failures affected residents and placed them at risk of decline in health status.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 7 % based on 3 errors out of 40 opportunities, which involved 3 of 9 residents (Resident # 13, #43 and Resident #18) reviewed for medication administration. 1. MA A failed to administer Cyanocobalamin (a form of vitamin B12= used to treat and prevent a lack of vitamin B12- may cause anemia ( condition in which the red blood cells do not bring enough oxygen to the organs ) to Resident # 13 according to physician orders. 2. MA A failed to administer Vitamin D (Cholecalciferol = used for vitamin D deficiency = also used with calcium to maintain bone strength ) to Resident #43, according to physician orders. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (Halls 300 medication carts ) of 3 medication carts reviewed for medication storage. - The facility failed to ensure the 300 hall medication carts did not contain nasal spray, topical gels and ointment that were opened labeled with the resident's name and not dated . This failure could place residents at risk of adverse medication reactions and infections . Findings Include: During observation on 01/29/25 at 09:11 AM, the following medications were found in the medication carts for 300 hall with LVN C. There were stickers on the medications to document open date: [...]

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 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1was provided personal grooming (dry patches and flaky skin) by facility staff. This failure could place residents at risk for not receiving care and services for ADL.

Inspectors wroteBased on observation, interview and record review , the facility to ensure a resident with pressure ulcers received nesessary treatment and services consistant with professional standards of practice, to promote healing, pevent infection a for 1 out of (Resident #1) of 2 residents reviewed for pressure ulcers. -The facility failed to ensure Wound Care Nurse followed proper wound care procedure during Resident #1's wound dressing change. This failure could place residents at risk for worsening existing pressure injuries, infection, pain, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 2 staff (The Wound care nurse) reviewed for infection control. 1. The facility failed to ensure The Wound care nurse followed proper infection control and PPE procedure during wound care treatment for Resident #1. This failure could place the residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's Comprehensive Care Plan was developed and Implemented for 1 (CR #1) of 4 residents reviewed for care plans. The facility failed to address CR#1's wound care and adls needs in the care plan. This failure could place residents at risk of not having necessary care and services provided to address the residents individual needs.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (CR #1) of 21 residents reviewed for abuse and neglect. -The facility failed to ensure that CR #1 was free from sexual abuse after facility staff assessed the resident to have unexplained vaginal bleeding, a sign and symptom of sexual abuse on 09/14/2024 and 09/24/2024 that resulted in CR#1 being transferred to a local hospital on [DATE] with semen being found in her urine culture and acute injury found during genital exam. An Immediate Jeopardy (IJ) was identified on 9/27/2024. The IJ template was provided to the facility on 9/27/24 at 5:20pm. [...]

Inspectors wroteBased on interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse for 1 (CR#1) of 21residents reviewed for reporting abuse. -The facility failed to implement their written policy of Abuse, when facility staff failed to report to the Administrator and investigate when CR #1 was assessed with vaginal bleeding on 09/14/2024 and refused perineal care (washing the genital and anal areas), requested not to be touched, and feared being touched all signs and symptoms(s/s) of sexual abuse on 09/24/2024. CR#1 was transferred to a local hospital on 9/24/2024 and semen was present in her urine sample. An Immediate Jeopardy (IJ) was identified on 9/27/2024. The IJ template was provided to the facility on 9/27/24 at 5:20pm. [...]

Inspectors wroteBased on observation, interview, 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, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (CR#1) out of 21 residents reviewed for reporting. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated and prevent further potential abuse or mistreatment while the investigation was in progress for 1 of 21 residents (CR#1) reviewed for abuse. 1. The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed to thoroughly investigate and report when CR#1 was assessed with unexplained vaginal bleeding on 09/14/2024, refused perineal care (washing the genital and anal areas), requested not to be touched, and feared being touched all signs and symptoms (s/s) of sexual abuse on 09/24/2024. CR#1 was transferred to a local hospital on 9/24/2024 and semen was present in her urine sample. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (CR #2 and CR#3) out of 21 residents reviewed for quality of care in that: 1. LVN F failed to notify the hospice nurse, Non-Emergency Medical Service (EMS), and local hospital that CR#2 required assessment for sexual abuse after being observed with vaginal bleeding a sign and symptom of sexual abuse. CR#2 arrived at the hospital on [DATE] at 7:52am and had not been assessed for the concern for sexual abuse at 11:19am. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE]at 10:26am. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consult with the resident's physician; and notify the resident representative for 2 of 21 residents (CR#2 and CR#3) reviewed for change of condition, in that, 1. LVN G failed to notify CR#3's Primary Care Physician that the resident was observed having difficulty breathing on [DATE] when transporting resident via non-ermergency which resulted in delay of emergency medical care. 2. LVN G failed to notify CR#3's Responsible Party that the resident had difficulty breathing and signs of a seizure [DATE]. 3. LVN F failed to notify the Responsible Party that CR#2's hospital transfer on [DATE] required assessment for a concern of sexual abuse after being observed with vaginal bleeding. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:48pm. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 21 residents (CR#1 and CR#3) reviewed for administration. 1. The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed to thoroughly investigate and accurately report an allegation of sexual abuse, when CR #1 was assessed with signs and symptoms of sexual abuse on 09/14/2024 for vaginal bleeding an on 09/24/2024 for refused perineal care (washing the genital and anal areas), requested not to be touched, and feared being touched. CR#1 was transferred to a local hospital on 9/24/2024 and semen was present in her urine sample. 2. [...]

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 in locked compartments for 1 of 3 medication carts reviewed for storage of drugs. LVN AJ failed to ensure a medication cart was locked and supervised when reviewed for storage of drugs, when she left the 100/400 hall cart unlocked while asleep. This failure could place residents at risk for drug diversion, drug overdose, and accidental or intentional administration to a resident, which could lead to deterioration of general health.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that personnel provide basic life support including CPR, to a resident requiring such emergency care prior to the arrival of medical personnel and subject to related physician orders and the resident advance directive for 1 resident (CR #1) of 13 residents reviewed for quality of life. The facility failed to immediately initiate CPR at 3:41 p.m. on [DATE] when CR#1 was found unresponsive, causing a 3-minute delay. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:49p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 Medication Carts and one medication room reviewed for medication storage. 1. The facility failed to ensure the Medication room cabinet did not have 3 bottles of expired vitamin ( B-6) stored . 2. The facility failed to ensure the 300 hall medication cart did not have eye drops and vaginal creams were dated with open dates. 3. The facility failed to ensure the 100 and 400 hall had 5 eyes drops were dated with no open dates . [...]

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 3 residents (Residents #35 and #94) reviewed for infection control practices. 1. CNA A did not utilize appropriate hand hygiene during Foley catheter care for Resident #35 2. CNA A did not utilize appropriate hand hygiene during incontinent for Resident #94 These failures could place residents at risk of infection or a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for in 1 of 5 residents (Resident #35) reviewed for catheters . 1. The facility failed to secure Resident #35's urinary catheter and tubing. 2. -The facility failed to ensure CNA A properly cleaned Resident #35 during incontinent care. These failures could place residents at risk for urinary tract infections (UTI) , urethral erosions, discomfort, skin breakdown, and a decreased quality of life.

Inspectors wroteBased on observation, 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 4 residents (Resident # 12) reviewed for :pharmaceutical services. MA A administered Resident #12 Pregabalin capsules and extended -release almost 2 hours after the scheduled timeframe. (Pregabalin is a long -acting a medication used to relieve neuropathic pain) pain from damaged nerves that can occur in your arms, hands, fingers, legs, feet or toes if you have diabetes and certain types of seizures ( Focal seizures=a sudden uncontrolled burst of electrical activity in the brain). This deficient practice could place residents at risk for not receiving a therapeutic effect.