KATY, TX - Federal health inspectors documented multiple safety and care violations at The Grace Care Center of Katy (operating as Falcon Point Post Acute) during a January 10, 2025 inspection, including failures in background screening, infection control, and medication management that placed residents at risk.
The facility, located at 23553 West Fernhurst Drive, received citations spanning staff credentialing, respiratory care protocols, pharmaceutical services, and infection prevention practices.
Director of Nursing Lacked Required Background Check
Inspectors discovered the facility's Director of Nursing (DON) had not undergone the required annual background screening for 18 months. The DON's last Employee Misconduct Registry check occurred on July 28, 2023, with no subsequent verification until January 9, 2025—only after surveyors brought the lapse to facility leadership's attention.
Federal regulations require nursing homes to conduct annual background checks on all staff to verify they remain employable and have not been barred from working with vulnerable populations due to abuse, neglect, or exploitation findings.
The facility's Human Resources Coordinator acknowledged during interviews that annual background checks were her responsibility and described the oversight as unintentional. The Executive Director expressed uncertainty about whether annual checks were mandatory but acknowledged that failure to complete them could allow barred individuals to continue working with residents.
Annual background screening serves as a critical safeguard in long-term care settings. Staff members may face professional discipline or criminal convictions after initial hiring that would disqualify them from continued employment. Without regular verification, facilities risk employing individuals who pose documented threats to resident safety.
Improper Oxygen Equipment Handling Creates Infection Risk
Inspectors observed multiple infection control violations related to respiratory equipment for a resident requiring supplemental oxygen at night. On January 7, 2025, surveyors found the resident's oxygen tubing dated January 6 lying on the floor rather than stored in a protective bag.
Two days later, the same tubing remained improperly stored, draped across the oxygen machine. When a registered nurse removed the equipment, she failed to don gloves before handling it and carried the tubing through the hallway without placing it in a bag.
The nurse acknowledged during interviews that oxygen tubing should be stored in plastic bags when not in use and that she should have worn gloves and contained the equipment before transport to prevent cross-contamination. She stated she was unaware the resident used oxygen therapy.
Respiratory equipment that contacts mucous membranes can harbor bacteria and viruses. When tubing touches non-sterile surfaces like floors, it becomes contaminated with environmental pathogens. Improper handling and storage of such equipment creates transmission pathways for respiratory infections between residents and staff.
The facility's Infection Control Nurse confirmed proper protocols require placing unused oxygen tubing in sealed bags, donning gloves before handling potentially contaminated equipment, and containing items during transport to disposal areas.
Expired Medications Remained in Storage
During inspection of the medication room serving the long-term care unit, surveyors discovered five syringes of heparin flush solution with July 2024 expiration dates—six months past their shelf life.
Heparin flush is used to maintain patency of intravenous lines, including peripherally inserted central catheters (PICC lines) and midline catheters. The registered nurse interviewed stated no current residents required this treatment, and the last resident with such access had been discharged months earlier.
Medication efficacy declines after expiration dates as chemical compounds degrade. Expired heparin flush may fail to prevent catheter occlusion, potentially necessitating line replacement through additional invasive procedures. While the facility had no current need for these medications, their presence in active storage indicated systemic failures in medication room monitoring.
The Director of Nursing stated the night shift nurse was responsible for checking medication rooms for expired items, while the Assistant Director of Nursing reported conducting checks two to three times weekly. Despite these assigned responsibilities, the expired medications remained accessible for six months.
Pharmaceutical management regulations require facilities to establish procedures ensuring accurate acquiring, receiving, dispensing, and administering of all drugs. Maintaining expired medications in active storage violates these standards and creates risk of inadvertent administration.
Infection Control Signage Delayed for New Admission
A resident admitted January 6, 2025 with draining skin lesions, an indwelling urinary catheter, and active urinary tract infection did not receive required infection control signage until the evening of January 8—a two-day delay.
The resident had been hospitalized for cellulitis, multiple superficial skin wounds, excoriations, and urinary tract infection before transfer to the nursing home. Medical records documented an autoimmune condition causing bullous pemphigoid, a rare disorder producing large fluid-filled blisters that can drain infectious material.
During the delay period, no personal protective equipment was stationed outside the resident's room, and no signage alerted staff to implement contact precautions. The resident confirmed to inspectors that her lesions sometimes produced drainage.
Contact precautions require healthcare workers to wear gowns and gloves during care activities that involve touching the resident or potentially contaminated surfaces. These barriers prevent transmission of pathogens from infected wounds, catheters, or body fluids to other residents through staff hands and clothing.
The facility's Infection Control Nurse, who started December 15, 2024, stated she placed the signage on January 8 after recognizing the transmission risk. She confirmed standard practice required posting such alerts for residents with wounds, intravenous access, feeding tubes, urinary catheters, and active infections.
Staff Failed to Use Required Protective Equipment
Even after infection control signage was posted, nursing assistants failed to don complete personal protective equipment during care activities. On January 9, two certified nursing assistants entered a resident's room wearing only gloves—no gowns—to provide incontinence care.
The resident had a gastrostomy feeding tube and required contact precautions due to potential colonization with multidrug-resistant organisms. The resident's care plan specifically stated team members must wear gowns and gloves during high-contact activities including bathing, transferring, hygiene, changing linens, and toileting assistance.
Both nursing assistants acknowledged during interviews they forgot to wear full protective equipment. This lapse occurred despite visible infection control signage on the resident's door and supplies stationed immediately outside the room.
Feeding tubes breach the body's natural barrier defenses, creating direct pathways for bacteria to enter the gastrointestinal tract. Residents with such devices face elevated risks of infection with antibiotic-resistant bacteria. When healthcare workers fail to use barrier precautions, they can transfer these pathogens between residents through contaminated clothing and skin.
Inadequate Incontinence Care Practices
The same observation revealed additional care quality concerns. The resident's brief was heavily saturated with urine extending to the lower back, and the draw sheet beneath was soiled. The nursing assistants had last provided incontinence care around 11:15-11:30 AM—nearly three hours earlier.
During the care provided, staff failed to thoroughly clean the resident's perineal area, leaving fecal residue after using disposable wipes. The resident's registered nurse stated he had checked the resident at 11:00 AM and determined incontinence care was not needed at that time.
Facility policy and the resident's care plan required checking for incontinence and providing care at minimum every two hours. Prolonged exposure to urine and feces increases risks of skin breakdown, pressure injuries, and urinary tract infections. Incomplete cleaning during care provision fails to remove bacteria that can ascend the urethra and cause bladder infections.
Research consistently demonstrates that frequent incontinence care with thorough perineal cleansing reduces urinary tract infection rates in nursing home populations. The resident had recently completed antibiotic treatment for acute cystitis, making proper hygiene practices particularly important to prevent recurrence.
Facility Response and Oversight
The inspection occurred during a standard health survey conducted by federal and state surveyors. The facility operates under Medicare and Medicaid certification, subjecting it to regular compliance reviews.
Citations were issued at the minimal harm level, indicating violations had the potential to cause harm but no evidence documented that actual harm occurred. Facilities must submit correction plans detailing how identified deficiencies will be remedied and prevented going forward.
The multiple infection control citations point to systemic gaps in the facility's prevention program rather than isolated incidents. Effective infection control requires consistent leadership, clear accountability, staff education, and monitoring systems to verify protocols are followed.
Residents and families can access the complete inspection report through Medicare's Care Compare website or request copies from the facility. The report provides detailed findings that may inform care decisions and oversight by resident representatives.
The facility's performance on these core safety measures raises questions about quality oversight mechanisms and whether leadership allocates sufficient resources to infection prevention, pharmaceutical management, and human resources functions essential to resident protection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Grace Care Center of Katy from 2025-01-10 including all violations, facility responses, and corrective action plans.
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