Memorial City Nursing And Rehabilitation Center

CNA B stated she worked on 03/04/2026 beginning her shift at 07:00 a.m.

She stated ADON A instructed her to transfer Resident #21 who was sitting in a wheelchair across from the nurse's station into bed.

She stated she asked CNA C to assist and the transfer.

She stated she had not recalled anything out the ordinary with the resident.

She stated she could not recall any more details from that morning, but stated the resident exhibited tearfulness or complaints or desire of wanting her cellphone.

She stated had she, she would have reported those behaviors immediately to the resident's nurse.

She stated she was not made aware on 03/04/2026, the resident pulled the fire alarm and called 911 repeatedly and heard comments from other staff this week the behavior was contributed by the resident's anxiety.

During an interview on 04/27/2026 at 03:35 p.m., CNA A stated she worked on 03/03/2026 from 7:00 p.m. to 7:00 a.m. on 03/04/2026 and was responsible for Resident #21's care.

She stated at 04:00 a.m., she responded to the residents' call light when the resident asked for snacks and drinks.

She stated the resident pushed the call light again and the resident asked to get out of bed.

She stated she informed LVN A and LVN A told her it was too early for the resident to get up.

She stated that the resident insisted on getting up and she informed LVN A again.

She stated LVN A assisted her get the resident out of the bed and into a wheelchair.

She stated that LVN A rolled the resident into the hallway so that LVN A could have eyes on the resident while the staff made their final round of the shift.

She stated the resident made no requests to go to the hospital or no complaints about her cellphone.

She stated had she been aware, she would have reported the events to the nurse in charge.

She stated she was not aware that the resident had called 911 repeatedly and had pulled the fire alarm.

She stated she received in-service training on ANE and stated that following were forms of abuse: verbal, sexual, physical, seclusion, financial, and mental.

She stated that the ADM was the abuse coordinator of which all forms of abuse were reported to.

She stated in the event that the ADM was unavailable or the perpetrator, he would report the abuse to the nurse in charge, and the compliance line.

She stated she also received in-service training on the resident's right to have the cellphone and call whoever they want.

She stated staff were not to take any resident's property including a resident's cellphone and all resident phones were to be charged in a resident's room and nowhere else by staff.

During an interview on 04/27/2026 at 6:38 p.m., CNA E stated on 03/03/2026 she came on shift at 11:00 p.m. until 7:00 a.m. on 03/04/3036.

She stated on 03/04/2026, she answered Resident #21's call light and the resident was on the phone, and they individual was asking the resident questions and the resident was complaining about something, but she does not recall what the complaint was or who the resident was talking to because the resident asked the nurse to speak to the person on the phone.

She stated she took the resident's phone to LVN A at the nurse's station and went back to work.

She stated then LVN A asked her to assist in getting the resident out of the bed and into the wheelchair.

She stated during the transfer the resident made no complaints and was not in pain.

She stated when she left her shift at 07:00 a.m., the resident was sitting in front of the television calm.

She stated she had not seen the resident crying or complaining of pain, or of not having or wanting her cellphone.

She stated she was not aware when and when or if LVN A returned the resident's phone to her after speaking to the caller on the resident's phone.

She stated she was not aware if the resident's phone was at the nurse's station or if it was being charged while at the station.

She stated she had not seen or known if EMT or the fire department responded to 911 calls made by the resident or the pulling of the fire alarm.

She stated she

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Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055

During an interview on 04/27/2026 at 11:41 a.m., the ESQ.

She stated even though the out of state address listed on the resident's discharge notice was

contact with a group home in the area to assure the resident had a safe discharge from the facility.

She stated a new discharge notice was reinitiated and planned to be send out on this date to the resident.

Record review of policy titled Transfer and Discharge (including AMA) dated 03/05/2025, reflected: Policy: It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances.

This policy applies to all residents regardless of their payment source.

Policy Explanation and Compliance Guidelines:1.

The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's need.2.

Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions:a.

The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.b.

The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the service provided by the facility.c.

The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.d.

The health of individuals in the facility would otherwise be endangered.e.

The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility.

Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay.3.

The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand.

The notice will include all of the following at the time it is provided:a.

The specific reason and basis for transfer or discharge.b.

The effective date of transfer or discharge.c.

The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.e.

The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.f.

Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h.

The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.4.

Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident.

Exceptions to the 30-day requirement apply when the transfer or discharge is affected because:a.

The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident;.

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Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055

During an interview on 04/28/2026 at 11:29 a.m., RRN A stated that when a resident discharges from the facility with an anticipated return that does not result in a readmission, the facility must manually complete a discharge deletion so that the care plan closes out and no further MDS tasks trigger for completion. He stated it was the facility's responsibility to track CR #154's progress after discharging to the hospital to determine where the resident when once released. He stated he could not see in the CR's progress notes where the resident was once discharged from the hospital. He stated since it appears that tracking had not occurred, it explained why CR's discharge was not manually changed from anticipated returned to returned not anticipated. He stated it was his understanding that the facility as well as RRN should have been triggered after CR had not readmitted within 30 days. He stated he was not aware why no triggers were initiated. He stated that there were no negative or financial effects from the lack of correcting the discharge assessment, only paper compliance with CMS.

Record review of policy titled Policy Assessment Frequency/Timeliness Date Implemented: and dated 10/24/2022 reflected, Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. 9. A significant correction assessment will be completed no later than the 14th calendar day after determination that a significant error in a prior OBRA assessment occurred. 11.

Part A PPS discharge assessment must be completed within 14 days after the end date of the most recent Medicare stay (14 calendar days). If combined with an OBRA discharge assessment, it must be completed 14 days after the ARD of the OBRA discharge date .

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Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055

in-service training on 04/27/2026, that covered reporting change of condition and reporting a resident's pain immediately to the resident's nurse and documenting the pain in POC.

She stated in the event that the resident's nurse had not responded to the report of pain immediately she would report the pain to the ADON and the DON, and double back to ensure the pain was assessed.

She stated the following were forms of abuse to report to ADM who was the abuse coordinator: verbal, mental exploitation, sexual, and physical.

She stated in the absence of the abuse coordinator she would report the abuse to the compliance hotline and the state.

During an interview on 04/28/2026 at 10:24 a.m., with the ADM and the DON, the DON stated the negative effects of not addressing Resident 21's pain, could have caused the resident increased pain and pain that was not addressed.

She stated had she been made aware the resident's pain had not been addressed by LVN A, she would have terminated LVN A that day.

The DON stated it had been her expectation that if a resident made a report of pain, the resident's nurse would perform a pain assessment, notify the manager on duty, and the resident's MD, check orders for pain medication, and administer the medication.

She stated if no pain medication was ordered or the order the pain medication order was not effective, she expected that the MD would be further informed a new order for pain received, and complete further pain evaluations to document any changes in the resident's pain.

She stated to post the pain report, the residents received quarterly pain assessment.

The ADM agreed with the DON's statements on pain and stated he would have reported the incident as abuse, and suspended LVN A pending an investigation of the allegations.

Record review of policy titled Notification of Changes dated 10/24/2022, reflected: Policy.

The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.

Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.

Record review of in-service training dated 04/24/2026 titled: Responding to Call lights/Cellphones was conducted by DON and presented to all the facility staff reflected: All changes in condition must be reported to the MD/NP, DON and RP.

Non-clinical staff report any noticeable changes to the charge nurse and then the manager on duty if the charge nurse was not available.

Record review of in-service training dated 04/25/2026 titled: Addendum: All changes in a resident's condition must include a documented pain assessment. If a resident calls 911 or the fire department, they have the right to receive evaluation and treatment.

The resident has the right to be transferred out for treatment per their request.

Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.

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Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055

services of a licensed pharmacist.

services (including procedures that assure the accurate acquiring, receiving, dispensing, and

(Resident #30, Resident #41) reviewed for medication storage and labeling.

The facility failed to ensure nurses dated Residents #30 and 41's opened insulin glargine (a medication prescribed to help the body manage blood sugar levels) pens and discarded them within 28 days of opening, on 04/24/2026.This failure could place residents at risk of receiving medications that were less effective or expired and the risk of contamination or chemical degradation (change of a substance into something else, often making it weaker, useless, or harmful).

Findings included:

Record review of Resident #30's Provider Orders dated 04/09/2026, revealed an active order to receive insulin glargine 100 units/ml multiple-dose pen.

Inject 20 units SQ (under the skin) one time a day for diabetes (a disease in which the body cannot make or properly use insulin).

Record review of Resident #41's Provider Orders dated 03/11/2026, revealed an active order to receive insulin glargine 100 units/ml multiple-dose pen.

Inject 30 units SQ one time a day for diabetes.During an observation of Hall 100's medication cart and interview on 04/24/2026 at 12:08 p.m., revealed, staff opened and dated 2 insulin glargine, 100 units/ml multiple-dose pens and kept them in the medication cart beyond 28 days of the opening date.

The insulin pens belonged to Resident #30 and #41.

Staff opened and dated both insulin pens on 03/23/2026.RN Q stated she should have checked the insulin pens opening dates before each administration and discarded them after 28 days of opening. RN Q added if nurses kept using the insulin pens after 28 days of opening, residents could receive insulin that was less effective in controlling their blood sugar levels, RN Q stated she was unaware the insulin pens were expired.

During an interview on 04/24/2026 at 1:04 p.m., the DON stated she expected all nurses to check insulin pens for opening dates before each administration and discard them after 28 days of opening.

The DON stated she spot checked insulin pens for expiration dates weekly.

The DON stated she spot checked the facility's medication carts for expired medications last week.

The DON added if nurses kept using the insulin pens after 28 days of opening, residents could receive insulin that did not work as prescribed.

Record review of the facility's Insulin Pen Policy dated 07/03/2023, revealed .Policy: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge.Policy Explanation and Compliance Guidelines:9.

Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation.Procedure:e.

Check the expiration date on the pen.

Discard if expired.

Record review of the most current manufacturer's guide for insulin glargine pens dated August 2022, revealed staff must throw away all opened pens after 28 days of first use, even if there is insulin left in the pen.

Based on record reviews and interviews, the facility failed to ensure each resident is offered the

is medically contraindicated, or the resident has already been immunized for all residents.The facility failed to offer COVID vaccine to its residents upon admission to the facility.

This failure could place residents at risk of COVID.

The findings are:

During an interview on 04/24/2026 at 10:13 a.m., the ICPN stated the facility did not offer COVID vaccines to its residents.

She stated residents and residents' representatives always declined the COVID vaccination, so the facility stopped offering the vaccine.

She stated she was unaware the facility should have offered the vaccine to its residents and they could accept or refuse to receive it.

She stated she did not recall when the facility stopped offering the vaccine to its residents.

She stated if the facility did not offer the vaccine to residents, they could be at a higher risk of COVID disease.

During an interview on 04/24/2026 at 10:25 a.m., The DON stated she was unaware the facility should have offered the COVID vaccine to its residents and they could accept or refuse to receive it.

She stated she did not recall when the facility stopped offering the vaccine to its residents.

She stated if the facility did not offer the vaccine to residents, they could be at risk of COVID.

During an interview on 04/24/2026 at 10:29 a.m., The MD stated he was unaware the facility should have offered the COVID vaccine to its residents and they could accept or refuse to receive it. He stated if the facility did not offer the vaccine to residents, they could be at a higher risk of COVID disease.

During an interview on 04/24/2026 at 1:20 p.m., The administrator stated he was unaware the facility should have offered the COVID vaccine to its residents. He stated he did not recall when the facility stopped offering the vaccine to its residents.

He stated if the facility did not offer the vaccine to residents, they could be at risk of COVID disease.

Record review of the facility's Infection Control Policy, dated 05/13/2023, reflected, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Policy Explanation and Compliance Guidelines: 8. COVID-19 Immunization:a.

Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility.b.

Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions and contraindications to determine candidacy for the vaccination.c.

Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine.d.

Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance.

Record review of CDC (U.S. government agency responsible for protecting public health) ACIP (a CDC-chartered group of medical experts that develops recommendations for vaccine use in the U.S. civilian population) recommendations, dated October 2024, revealed .In October 2024, ACIP recommended that all persons aged ˆ65 years receive a second 2024-2025 COVID-19 vaccine dose 6 months after their last dose.

What are the implications for public health practice?Adults aged ˆ65 years should receive 2 doses of 2024-2025 COVID-19 vaccine

Record review of CDC COVID Recommendations, dated 11/19/2025, revealed, .The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death.It is especially important to get your 2025-2026 COVID-19 vaccine if you are ages 65 and older.Vaccine protection decreases over time, so it is important to get your 2025-2026 COVID-19 vaccine.

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Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055