Heritage Park of Katy Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to ensure controlled drug counts were in order and reconciled for two of two medication carts observed during change-of-shift. -Two medication carts controlled medication counts were conducted without staff cross-checking the medications cards and controlled medication count sheets. -The staff did not state the name of the medication when calling out the resident name and quantity. -The facility policy did not require both staff to confirm the quantity being verbalized was the quantity written on the controlled medication count sheet. The failure placed residents at risk for controlled medications to not be available when needed, and for controlled drug diversion. Findings include:Observation on 02/19/2026 at 2:02 p.m., revealed MA A and MA B conducting the change-of-shift count of the controlled medications for the Hall 400 Medication Aide cart. MA A was standing in front of the controlled medication lockbox, which was open. The lockbox was located on the right/front side of the cart. MA B was standing in front…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: -Five dented cans were stored with other cans used for resident meals in the dry storage room. -Food items were not sealed and not dated in the dry storage room. These failures could place residents who received meals from the kitchen at risk for food borne illness. Findings included: Observation on 11/5/24 at 9:00 am of the dry storage room revealed the following: -One 111 oz can of tomato paste with a large dent in the middle of the can -One 106 oz can of spaghetti sauce with a large dent at the top of the seam -One 112 oz can of banana pudding with a small dent at the bottom of the seam -One 112 oz can of vanilla pudding with a small dent at the bottom of the seam -One 108 oz can of sweet potatoes in syrup with a large dent in the middle of the can -One 25 lb bag of light brown sugar not sealed and not dated -One 5 lb bag of grits not sealed and not dated Interview with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level 1 Residents with a positive trigger for mental illness were provided with a PASRR Level II assessment for 1 (Resident #79) of 5 residents reviewed for mental illness. The facility did not correctly identify Resident #79 as having mental illness in her PASRR Level 1 Screening. This failure could place five residents with psychiatric diagnoses to trigger a positive PASRR Level I evaluation at risk for not receiving a PASRR Level II screening and receiving needed care and services to meet their needs. Findings included: Record review of Resident #79's face sheet dated 11/5/24, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), unspecified psychosis, major depressive disorder (a mental health disorder characterized by persistently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviews, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (Resident #26) of 31 residents reviewed for base-line care plans. The facility failed to ensure (Resident #26) had a baseline care plan developed within 48-hours after admission with goals based on admission orders and interventions, PASRR recommendations, Physician's orders, therapy services, dietary orders, and social services. This failure could place newly admitted residents at risks of not receiving the proper care and continuity of services. Findings included: Record review of Resident #26's Face Sheet (undated) revealed, an [AGE] year-old female who admitted to the facility on [DATE] and with diagnoses which included: unspecified dementia, unspecified severity, with other behavioral, Alzheimer's disease (a brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (100 Hall Nurse Medication Cart) of four medication carts reviewed for storage of medications. The Nurse Medication Cart for 100 Hall had a torn protective seal on the back of Resident #211's Tramadol HCL 50mg (a narcotic used to treat moderately severe pain) medication blister pill card (a type of medication packaging, with multiple small, sealed compartments that hold individual doses of medication) found in the locked narcotic drawer during review of medication carts. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, infection, and drug diversion. Findings included: Record review of Resident #211's face sheet undated reflected a [AGE] year-old female first admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included heart failure (the heart is not pumping adequate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 2 of 4 residents (Resident #1, and Resident #3) reviewed for incontinent care. - 1. The facility failed to ensure Resident #1's foley tubing was not touching the floor while Resident #1 was propelling himself between the nursing station and medication room. - 2. The facility failed to ensure Resident # 3's foley bag and tubing were not touching the floor while Resident #2 was laid in bed. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: 1. Record review of Resident #1's face sheet dated 03/05/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included: dementia (loss of thinking, remembering, and reasoning, which may interfere…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 2of 5 residents (Resident #2, and Resident #3) reviewed for call lights. The facility failed to have call light was within reach for Resident #2 and Resident #3 while the residents was in bed. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life. Findings included: Record review of resident #2's Face sheet revealed a [AGE] year-old female was in admitted to the facility on [DATE]. Resident #2 had diagnoses which included: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), diabetes mellitus (high blood sugar), and Hypertension (high blood pressure). Record review of resident #2's quarterly MDS dated [DATE] revealed a BIMS of 09 indicating moderate impaired cognition. Further review revealed Resident #2 needed total care assist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 1of 5 residents (Resident #4) reviewed for ADLs. 1. The facility failed to ensure Resident #4 was provided personal grooming (fingernail care) by facility staff. This failure could place residents at risk for discomfort, and dignity issues. Findings included: 1. Record review of Resident #4's face sheet dated 03/05/24 revealed a [AGE] year-old female admitted to the facility on 1. 01/01/24. Resident #4 had diagnoses which included: dementia (loss of thinking, remembering, and reasoning, which may interferes with a person's daily life and activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #4's MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview, and record review, the facility failed to ensure allegations of abuse and neglect are thoroughly investigated and report results of the investigation to the stage agency within 5 working days of the incident for 2 of 9 residents (Resident #50 and #84) reviewed for allegations of neglect as evidence by: 1. The facility failed to report an unwitnessed fall to the state agency when Resident #84 was found on the floor had a large hematoma to the top of her head and was transferred to the hospital . Resident #84 could not state how she fell. 2. The facility failed to report an unwitnessed fall to the state agency when Resident #50 was found on the floor. Resident #50 was sent to hospital on 7/25/23 and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. These failures could place residents at the facility not having their complaints and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dialysis service was provided consistently with professional standards of practice for 1 of 3 residents (Residents #72) reviewed for dialysis services. The facility failed to keep ongoing communication with the dialysis facility for Resident #72. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #72's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] was readmitted on [DATE] . Her diagnoses included fluid overload, retention of urine, dependence on dialysis, muscle wasting and atrophy and abnormalities of gait and mobility. Record review of Resident #72's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #72's care plan undated revealed the resident has diagnosis of renal failure and received dialysis. Goal and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 each resident for 1 of 8 (Resident #32) reviewed for medication administration. The facility failed to ensure that LVN A did not administered Resident #4's Prednisolone Acetate Ophthalmic (eye drop medication used to treat inflammation of the eyes) to Resident #32. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Resident #32 Record Review of Resident #32 electronic face sheet dated 09/08/23 revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #32 had the diagnosis of inflammation of the eyes. Record Review of Resident #32 Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 10, which indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure drugs and biological's 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 when applicable for 2 of 4 medication Carts reviewed for medication storage. The facility failed to ensure the medication (med) chart 100-hall did not have the expired medications Packets of Arginaid ( Arginne powder) ( used to help support the unique nutritional needs of individuals with wounds). The facility failed to ensure the Nurses medication carts 300-hall did not have the opened and undated medications: *Alphagan Brimonidine tartrate ophthalmic solution 0.1% ( used for an alpha adrenergic receptor agonist of indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension). *Prednisolone Acetate ophthalmic suspension 1 vial for ( drug used to treat inflammation of the eyes caused by certain condition), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an adequately furnished space for dining and activities for 1 of 1 dining room and 1 of 1 activity room reviewed for dining and activity rooms. The facility did not provide an adequately furnished dining room or activity room for dining and resident activities. This failure could place the residents at risk for psychosocial harm and decreased quality of life. Findings included: Record review of the face sheet indicated Resident #55 was a [AGE] year-old male and was admitted on [DATE] with diagnoses including dementia, behavior disturbance, psychotic disturbance, mood disturbance anxiety and muscle wasting and atrophy (thinning or loss of muscle tissue). Record review of the MDS dated [DATE] indicated Resident #55 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated he was moderately cognitively impaired. The MDS indicated Resident #12 needed supervision and 1-person physical assist for all activities of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.