Brookdale Galleria

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

12:23 PM, the Speech Pathologist said she provided services to Resident #1 for his dysphagia. She said

the resident was on swallowing precautions, so he was ordered a soft diet ( dietary medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow, so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. In an interview on 10/31/25 at 12:56 PM, the MDS Nurse said she was responsible for adding a resident's diagnosis to their medical record and she completed MDS(s) and care plans along with her colleague that was currently on leave. She said a resident's diagnosis was retrieved from hospital paperwork, doctors visits, and therapy assessments. The MDS Nurse said the information from a resident's MDS was developed from the diagnosis, the resident

interview and other clinical documentation. She said Resident #1 had a modified diet and was managed by speech therapy so dysphagia should be included in his diagnosis. After she reviewed Resident #1's chart

she said, the resident had a diagnosis of dysphagia noted in his ST notes on 09/03/25 so it should have been a diagnosis on his face sheet, documented in his MDS, and there should be an associated focus area

in his care plan. The MDS Nurse said on 10/30/25, when the surveyor entered the facility, Resident #1's face sheet, MDS, and Care Plan were inaccurate because they did not address his dysphagia and need for crushed medications. She said his diagnosis and care plan was updated on 10/30/25 after the surveyor alerted the facility to the discrepancy. The MDS Nurse said incorrect assessments/diagnosis could place residents at risk for not receiving proper care because the MDS and diagnosis did not indicate the resident's swallowing problems which resulted in the resident not having an accurate care plan. She said failure to care plan diagnosis like dysphagia could place residents at risk for choking and death. An attempt was meant on 10/31/25 at 02:29 PM to contact the Interim DON in regards to accuracy of diagnosis, assessments and care plans via telephone. A voicemail and text message were sent, the Interim DON did not return the surveyors call prior to exit. Record review of the facility's policy titled Certifying Accuracy of Resident Assessments with no revision date revealed, Policy Statement: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Policy Interpretation and Implementation: 1. Any health care professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge. 4. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the resident assessment coordinator, who is a registered nurse. There was no reference to the accuracy of assessments.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookdale Galleria

2929 Post Oak Blvd Houston, TX 77056

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. In an

interview on 10/31/25 at 12:56 PM, the MDS Nurse said she was responsible for adding a resident's diagnosis to their medical record and she completed MDS(s) and care plans along with her colleague that was currently on leave. She said a resident's diagnosis is retrieved from hospital paperwork, doctor's visits and therapy assessments. The MDS Nurse said the information from a resident's MDS was developed from

the diagnosis, the resident interview and other clinical documentation. She said Resident #1 had a modified diet and was managed by speech therapy so dysphagia should be included in his diagnosis. After she reviewed Resident #1's chart she said, on the resident had a diagnosis of dysphagia noted in his ST notes

on 09/03/25 so it should have been a diagnosis on his face sheet, documented in his MDS and there should be an associated focus area in his care plan. The MDS Nurse said on 10/30/25, when the surveyor entered the facility, Resident #1's face sheet, MDS, and Care Plan were inaccurate because they did not address his dysphagia and need for crushed medications. She said his diagnosis and care plan was updated on 10/30/25 after the surveyor alerted the facility to the discrepancy. The MDS Nurse said incorrect assessments/diagnosis could place residents at risk for not receiving proper care because the MDS and diagnosis did not indicate the resident's swallowing problems which resulted in the resident not having an accurate care plan. She said failure to care plan diagnosis like dysphagia could place residents at risk for choking and death. An attempt was meant on 10/31/25 at 02:29 PM to contact the Interim DON in regards to accuracy of diagnosis, assessments and care plans via telephone. A voicemail and text message were sent, the Interim DON did not return the surveyors call prior to exit. Record review of the facility's policy titled Comprehensive Care Plan revised November 2017 revealed, Policy Overview: A comprehensive, person-centered Care Plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment. Policy Detail: A. A person centered, comprehensive care plan will be developed and implemented in accordance with the following: 1. The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental and psychosocial wellbeing. 2. The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection forms, Therapy Evaluations, psychosocial and cognitive evaluations, physician assessments/consults. 4. Each resident's comprehensive care plan will describe: a. Resident goals for care and desired outcomes b. Identified resident issues, conditions, risk factors and safety issues c. The resident's unique characteristics and strengths.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookdale Galleria

2929 Post Oak Blvd Houston, TX 77056

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

consequences and crushing medications without orders was against regulations. In an interview on 10/31/25 at 10:22 AM, the Interim DON said she was not aware of Resident #1 having swallowing issues but failure to have orders to crush medications for those with dysphagia, who required it, could place residents at risk of aspiration and choking. In an interview on 10/31/25 at 10:41 AM, RN B said Resident #1 received medications crushed due to prevent choking or aspiration. She said Resident #1 loved to take his medications with applesauce, and medications require an order to crush medications and failure to receive

an order prior to administering could place residents at risk of adverse reactions while failure to have orders to crush medications for resident's with dysphagia could result in aspiration and choking. In an interview on 10/31/25 at 10:58 AM, LVN A said Resident #1 received his medication crushed, but she didn't know the reason why. She said prior to crushing medications there had to be an order in place, and failure to have orders for those who required their medications crushed could place them at risk of choking or aspiration.

LVN A said since she worked with Resident #1 and she had observed no issues with choking or discomfort.

In an interview on 10/31/25 at 11:03 AM, RN C said she did not crush medications for administration to Resident #1 because he did not have orders for crushed medications. She said an order was required prior to crushing medications and failure to have orders for crushed medications could result in aspiration and choking. RN C did not report any aspiration or choking with Resident #1. In an interview on 10/31/25 at 11:22 AM, LVN said Resident #1 had a modified diet due to chewing and swallowing problems and he had

an order to crush all medications when he arrived, so it must have fallen off his orders. She said prior to crushing medications, there should be an order in place. She said failure to have orders for crushed meds for residents with swallowing disorders could place them at risk for aspiration and choking. In an interview

on 10/31/25 at 12:23 PM, the Speech Pathologist said she provided services to Resident #1 for his dysphagia. She said the resident was on swallowing precautions so he was ordered a soft diet ( dietary medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. Record

review of the facility's policy titled General Dose Preparation and Medication Administration revised 11/15/24 revealed, 2.7 Facility staff should crush oral medications only in accordance with pharmacy guidelines as set forth in Resource: Oral Dosage Forms that Should Not Be Crushed and/or facility policy. 2.7.1 Exceptions to Should Not Crush medications may occur when physician/prescriber orders are documented in the medical record including a statement explaining why crushing the medication will not adversely affect the resident.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookdale Galleria

2929 Post Oak Blvd Houston, TX 77056

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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

under the change tubing task in the TAR. LVN A said she worked with Resident #2 over the weekend, and

she thought she changed the oxygen with the tubing. She said if she documented it, she should have done

it because she could not remember any issues with Resident #2's oxygen on the weekend of 10/26/25. She said failure to documents accurately, placed residents at risk of missed services or care and adverse reactions. In an interview on 10/31/25 at 10:22 AM, the Interim DON said O2 water and tubing should be changed every 7 days for infection control and to prevent contamination of the tubing and water She said failure to change the water and tubing could place residents at risk of infection and failure to humidify oxygen could result in drying of the nose, cracked and bleeding nostrils which result in discomfort. The Interim DON said when a nurse signed off on the MAR for changing the tubing they were also indicating that the water was changed, and when they signed off every shift they were signing off on checking that the humidifier had water, the tubing was in good shape, and oxygen being received was as ordered. The Interim DON said failure to document accurately could place residents at risk of inaccurate documentation, missed services/treatment, and care opportunities. In an interview on 10/31/25 at 10:41 AM, RN B said when she worked with Resident #2 overnight on 10/29/25, and the water for the humidifier was bubbling, so there was water in the bottle. She said Resident #2 did not have any issues with her nostrils or have any complaints of dry nose, cracking or bleeding. RN B said she missed the date on the water because she checked to ensure it was bubbling and the water and tubing were supposed to be changed every Sunday in

the evening to prevent contamination and infection. In an interview on 10/31/25 at 11:47 AM, LVN C said when she worked with Resident #2 on the evening shift on 10/29/25. She said she monitored the resident's oxygen level, the settings on the tank and monitored the water. LVN C said the water for the humidifier was low, but it was still bubbling and functioning. She said the water was changed every Sunday but if it emptied sooner, nurses could change it. LVN C said she didn't notice the date on the water was 10/20/25, and Resident #2 reported no respiratory issues on her shift. Record review of the facility's policy Oxygen Management Policy revised September 2025 revealed, Policy Overview: This policy provides guidance for

the safe storage and use of oxygen. B. Procedure 2. Oxygen Administration a. Verify that there is a physician's order for this procedure. Review the healthcare provider's orders or community protocol for oxygen administration. b. Review the resident's care plan to evaluate for any special needs of the resident.

1. 3. Oxygen Use: b. The nurse should monitor oxygen administration and record the resident's response to

oxygen therapy in the medical record. k. When humidifiers are used, they should be changed per the manufacturer's recommendation. Humidifiers should be checked periodically and changed as needed.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookdale Galleria

2929 Post Oak Blvd Houston, TX 77056

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 0732 Level of Harm - Potential for minimal harm Residents Affected - Many

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

of the form. Record review of the facility's policy titled Benefits Improvement Protection ACT (BIPA) Daily Associate Posting revised 10/20/25 revealed, Policy Overview: A daily schedule of licensed and unlicensed nursing associates who are responsible for resident care, should be posted in a prominent location, allowing associates, residents and visitors to view this information. The schedule should include the number and categories of nursing associates scheduled for each shift as well as the total number of hours worked.

Staffing is determined by resident population adhering to state and federal regulations. Clinical Services should complete the Clinical Services Sign-in Sheet on every shift. Policy Detail: 1. On a daily basis, a designated associate should post the community-specific number of direct caregivers scheduled for each shift in a 24-hour period by categories of nursing associates employed by the community, as well as the total number of hours worked by both licensed and unlicensed associates directly responsible for resident care. Direct care is interpreted as registered nurses, licensed practical/vocational nurses, and Certified Nursing Assistants (CNAs). 3. The designated associate member should post the community's name, current date and resident census, as well as the community specific shift schedule for a 24-hour period. The community decides when the 24-hour (daily) period for posting information begins and ends. 4. Data must be displayed in a clear and readable format and be posted in a prominent place readily accessible to residents and visitors.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookdale Galleria

2929 Post Oak Blvd Houston, TX 77056

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

as indicated. The policy did not address accuracy of documentation. Record review of the facility policy Oxygen Management Policy revised 09/25 revealed, Policy Overview: This policy provides guidance for the safe storage and use of oxygen. B. Procedure 2. Oxygen Administration a. Verify that there is a physician's order for this procedure. Review the healthcare provider's orders or community protocol for oxygen administration. b. Review the resident's care plan to evaluate for any special needs of the resident. 3.

Oxygen Use: b. The nurse should monitor oxygen administration and record the resident's response to oxygen therapy in the medical record. k. When humidifiers are used, they should be changed per the manufacturer's recommendation. Humidifiers should be checked periodically and changed as needed.

Event ID:

Facility ID:

If continuation sheet