Afton Oaks Nursing And Rehabilitation Center

F 0551

the facility.

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

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

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

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

would have decided on a different treatment plan. He said that he was not contacted to address interventions for a missed hemodialysis on 10/03/2025, he was notified of an elevated heart rate during dialysis that was addressed by another doctor. He said that he would not speak on risks to residents, or if Resident#2 should have been sent to the hospital. He said that his expectation is that staff make enter orders from the time of admission, follow orders, and make notifications to a physician when medications are not available, treatments are missed, and when there is a change in condition. In an interview and

observation on 10/10/2025 4:59pm at the beside of Resident#2 of ADON B to perform Resident#2's wound care treatment with MA E, and DON present. Both ADON B and MA E said that Resident#2 were medicated prior to treatment for pain. Observation of ADON B to cut away the bandage to Resident#2 left foot that was stuck to the wound without using a saline spray to loosen the bandage. ADON B was observed not to look a Resident#2 to non verbal signs of pain. Resident#2 was observed to show facial grimace. ADON B was asked if she would use a saline spray to loosen the bandage in which she did, and continued to pull the bandage from the wound. Resident#2 was observed with tears in both eyes. ADON B was asked what medication was used to manage the pain of Resident#2, to which she replied Extra Strength Tylenol. ADON B was asked to stop the treatment. DON A told ADON B to contact the physician to see if Resident #2 could have something stronger for pain. In an interview on 10/10/25 at 5:26pm with the Administrator A, she was told of the observation made of Resident#2's wound care and concern for pain management. Administrator A said the concerns were clinical concerns and she would have to speak with

the DON Ato gather more information on the sit

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

it down the hall and reported that the smell lingers into Resident #33's room. She stated she had not complained about the smell but reported Resident #33 has complained to corporate about the smell. In an

interview on 10/22/25 at 9:25am with Resident #37, the resident resides on the 300 hall. He stated he did not like the way his room or the facility smelled and stated who would like the smell. He stated the smell was worse in the hallway. He stated the smell was coming from one of the rooms on the 300 hall and stated

the residents in that room does not allow staff to wash their a**, change their diapers, or tend to their wounds. It smells sh** and rotten flesh. He stated he felt helpless because this was his home and he could not do anything about the smell. He stated if this was his own home it would not have this smell. He stated

the staff had not asked him how he felt about the smell, and no one had asked him if he wanted to change halls. In an interview on 10/22/25 at 9:35am with CNA-AJ, she reported there was a concern with odor on Hall 300 because some of the residents refuse care. She stated she could not think of words to describe

the smell but it was bad. She stated she did not know what the facility was doing about the smell but reported it has always smelled that way since she started working at the facility, she stated she started working at the facility in November 2024. She stated that this was the residents' home and they have a right to an odor free home. In an interview on 10/22/25 at 9:40am with Housekeeper-AL, she stated she had been employed at the facility for 2 months. She stated there was an issue with odor on the 300 hall. She stated the odor was indescribable and stated it had always smelled bad ever since she started working there and the smell had gotten worse. She stated she was told the source of the smell was from residents refusals of baths and wound care. She stated she cleans each room one time a day and the rooms of concern are cleaned two times a day. She stated she sprays odor neutralizer upon entering and exiting each room and she also sprays the hallways as she exits each room. She stated that she goes through 2-3 bottles of odor neutralizer a week for one hall to try to help the smell but it does not work. She stated the additional cleaning was not helping the odor. She stated that it was the residents' home, and they have the right to have an odor free home. In an interview on 10/22/25 at 10:20am with Resident #33, he did not have any concerns for the smell in his room or in the hallway. In an interview on 10/22/25 at 11:20am with Administrator-A, she stated she does daily observation rounds of the entire facility. She stated she had not observed a pronounced odor to any part of the facility. She stated she had only observed there to be a smell associated with incontinent care and that was normal from residents getting brief changes at every facility. She stated there had not been complaints or grievances about odors in the building. She stated housekeeping does have some targeted rooms that received additional cleaning at the back of 300 hall and 400 hall. Administrator-A sent an email to surveyors with the list of targeted rooms that get additional cleanings, but she reported she did not recall the reason as to why the rooms get additional cleanings. On 10/22/2025 at 1:06pm, a policy was requested for homelike environment, and it was not provided prior to exit.

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

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

if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41 PM with Administrator A, she said she did not always stay for daily clinical meetings with the clinical department heads after the daily stand-up meeting. She said she did not believe she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said the DON was the clinical oversight for the facility. She said the DON should review all new admissions, re-admission, change

in conditions, and the 24-hour report for accuracy. She said the DON should review all medical clinical records prior to a residents admission. In an observation on 10/10/2025 at 9:32 AM at the beside of Resident #2 revealed the resident was non-verbal or not interviewable. In an interview on 10/10/2025 at 9:38 AM with the in-house Hemodialysis Nurse, she said on 10/03/2025, Resident #2 could not receive hemodialysis due to a change in condition, which was an elevated heart rate around 120 beats each minute, she contacted the Nephrologist who ordered Metoprolol to Resident #2, and she communicated with Resident #2's nurse (name unknown) about the order for Metoprolol. She said Resident #2 was referred back to the facility nurse (name unknown) for further intervention and treatment. She said when a resident did not receive hemodialysis as scheduled, they were usually sent to the hospital to receive hemodialysis. She said she later found out Resident #2 was not sent to the hospital.In a phone interview on 10/10/2025 at 10:05 AM with RN A who worked the 10:00PM-6:00AM, said she notified NP A that Resident #2 had not received her hemodialysis on 10/03/2025, because her hea

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

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

there would be no reason for her to remain in the building without the medications, and the risk to Resident#2 would have been the infection could have worsen.? He said that it was important for staff to notify a physician of wounds upon admission and once identified.? He said that the standards were to continue with orders from the hospital until a wound care physician can take over or the primary physician makes changes to the treatment from the hospital.???? In a telephone interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident #2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records.? He said that he rounded with Resident #2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia.? He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day.?

He said that if he had been informed, he would have decided on a different treatment plan.? He said that he was not contacted to address interventions for a missed hemodialysis on 10/03/2025, he was notified of an elevated heart rate during dialysis that was addressed by another doctor.? He said that he would not speak

on risk to residents, or if Resident#2 should have been sent to the hospital.? He said that his expectation is that staff make enter orders from the time of admission, follow orders, an

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

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

interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident.

On 10/14/25 at 6:56 pm a request was made with the Administrator, DON, Corporate and Regional staff requested staff list, wound care list and medication orders status post wound care doctor B's visit on 10/13/25, no MAR to support pain medication audits. Still pending facility audit of Resident #2's transfer to

the hospital on [DATE REDACTED]. In an interview on 10/15/2025 at 6pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment.

She said if a resident were exhibiting signs and symptoms of pain, to stop the treatment or procedure, redo

the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. On 10/15/2025 at 4:44pm a request was made with the Administrator, DON, Corporate and Regional staff to review enteral feeding orders and medication orders for Resident #34 who was a new admission to the facility on [DATE REDACTED]. Observations on 10/16/2025 at 6:00 a.m.- 2:00 p.m. shift of 3 out of 5 residents for wound care, Resident #11, Resident #12, and Resident #20 who did not have adequate pain management prior to or during the wound observations and wound care treatments needed to be stopped.

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

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

on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. She was able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). The Administrator was informed that the immediacy was removed

on 10/16/2025 at 7:43 p.m. The facility remained out of compliance at a scope of pattern at a severity level of no actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 - Some

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

signs and symptoms of pain, she would stop the treatment or procedure, redo the assessment and check for any other orders or interventions and if interventions were ineffective, she would initiate an SBAR for pain and notify the MD and RP for the resident. LVN C stated if a resident were on dialysis, she would complete the required dialysis communication sheets before and after dialysis and notify the physician, as appropriate regarding any changes in the resident's condition. She stated once a resident had a change in condition, they were to do the change in condition-SBAR, call the physician, call the family and call the DON to notify them of the change in condition and follow the physician orders. She stated she thought the physicians came to see the residents weekly. She stated when working with any resident that was refusing care, the physician, DON, and family would be notified, and physicians' orders would be followed, and she would ensure it had all been documented. LVN C said that the physician and RP also need to be notified if

a resident did not receive any medication/s so new or different orders could be implemented. In an

interview on 10/16/2025 at 6:13pm with RN J, she stated she has been employed at the facility for 10 years.

She stated that she worked the 10pm-6am shift. She stated her last in-service was last night for abuse and neglect. She stated they also reviewed pain and abuse and neglect, and she was knowledgeable about the different types of abuse. She stated abuse was reported to the Administrator/Abuse Coordinator. She stated

she was in-serviced on the dialysis process, and that when working with a dialysis resident, she ensured

the resident was clean and dry and ensured that they were stable, which included assessing their vital signs. She sta

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 0921

prior to exit.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Afton Oaks Nursing and Rehabilitation Center

7514 Kingsley St Houston, TX 77087

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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #31 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. In an

observation on 10/20/25 at 02:05pm, approximately 16 flies were observed on Hall 300. In an interview/observation on 10/20/25 at 2:14pm with Resident #21- The resident was observed in his room lying in bed and there was a live fly on his blanket. There were 4 live flies observed on his wall. Resident #21 stated he sees flies in his room often, he stated he thinks the flies come from the towels the staff use to wipe the tables in the rooms. In an observation on 10/20/25 at 2:17pm with Resident #31, he was observed

in his room lying in bed and there were 2 live flies on his blanket and approximately 2 flies observed flying around the room. In an interview on 10/20/25 at 2:54pm with the Regional Compliance Nurse, he acknowledged that there were flies in the residents' room. He stated pest control has been called out to the facility to make additional visits. He stated they were initially coming out to the facility monthly but they now come out more often. Record review of the facility's service inspection report revealed the facility was treated 10/07/25. The facility was treated for House/Fruit/Blow/Flesh/Stable Flies, German Roaches and Fire Ants. The areas treated were the Dining-> Device Fly Light, Common Area>Device Fly Light1, Common Area->Device Fly Light2, Common Area->Device Fly Light3, Interior, Common area and Exterior;

the light traps were also inspected. Prior to 10/07/25, the facility was treated on 09/30/25. The facility was treated for American Roach and Bed Bugs. The area treated was the interior. The facility was not treated for flies during this visit. Record review of the facility's pest control policy dated 2012 reflected, The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. 1. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required.

Event ID:

Facility ID:

If continuation sheet