Lampstand Nursing And Rehabilitation

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

their rights to allow the person to continue to care for them after they have been asked not to. She stated it could degrade the resident or RP's trust in the facility. In an interview with Admin on 10/10/2025 at 4:52PM,

she stated if we allow staff to work with residents after the resident or RP requested for them not to be, she stated the resident or the RP may feel their rights are not being respected. She stated that we should honor

the requests of the RP as we would a direct request from a resident. In an interview with RNC on 10/10/2025 at 4:52PM, she stated it could distress them or trigger trauma to have someone continue to care for them after they have been told not to care for them. Record review of facility policy for Resident Rights (no date) reflected: RESIDENT RIGHTS.3.In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated.a. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative.b. The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law.4.The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.5.The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lampstand Nursing and Rehabilitation

2001 E 29th St Bryan, TX 77802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

A Focus area stating, Resident is resistive to care r/t (related to) TBI. Resident legs and arms are very stiff when staff try to turn him he pushes back with his body Date Initiated: 09/15/2025, with related interventions including, If resident resists with ADLs, reassure resident, ensure safety, leave and return 5-10 minutes later and try again. Date Initiated: 09/15/2025 Created by: DON. Record review of Resident #1's MD assessment on 09/19/2025 at 11:26AM, reflected Resident #1's condition was stable. Plan included continuing current medication orders and to continue supportive care. Review of facility policy Fall Policy reflected: Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk. Procedure 1. On admission, the nurse will complete a fall risk assessment for each resident. 2. If the resident is unable to assist in completion of the tool, or if medical records are unavailable,

the nurse may obtain the assistance of a family member or legal representative that is familiar with the resident's current functional status. 3. Fall Risk Assessment The Fall Risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing

the resident's medical history, social history, and current functional status. Information may be obtained by reviewing current medical records, interview with resident/family, or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated. The MDS completed on admission, quarterly and upon significant change will also assess for fall risk 4.

Appropriate interventions will be addressed immediately on the interdisciplinary plan of care.

Reassessment will occur after each fall. 5. Interventions will be resident centered. See Appendix A for Fall Intervention Methods on the following pages.17. Appropriate education will be provided to all staff members as needed on fall prevention. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE REDACTED] at 1:25PM. The IJ began on 9/12/2025 and ended 9/15/2025. The facility corrected the noncompliance before the survey began on 10/08/2025.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lampstand Nursing and Rehabilitation

2001 E 29th St Bryan, TX 77802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact

the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 6.

The nurse will monitor and reassess the resident's status and response to interventions. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if

the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions.The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE REDACTED] at 1:25PM. The IJ began on 9/12/2025 at 11:22PM and ended 9/15/2025. The facility corrected the noncompliance before the survey began on 10/08/2025.

Event ID:

Facility ID:

If continuation sheet