Deerbrook Skilled Nursing And Rehab Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

conversational, upset, and could not understand why the facility made a big deal of it. He said the facility follows the provider letter dated 8/24 and needed to report elopements within 24 hours to HHS.In an

observation on 10/22/25 at 4:45 p.m. of the street CR #1 allegedly walked down revealed cars consistently drove down the street at moderate speed. The posted speed limit was 45 mph. The nearby business where CR #1 was found was located near the freeway and on the opposite side of the street from the facility.In an

interview on 10/23/25 at 11:02 a.m. LVN K said one day when she was leaving work after 2:00 p.m. she saw CR #1 walking down the street in the direction of the freeway. She said she turned the car around to look for him but did not see him, she called the traveling DON to report CR #1 was out of the building. She said before CR #1 left the building, she last saw him at the nursing station around 2:00 p.m. She said he could have gotten hit crossing the street or dehydrated because it was hot that day. She said CR #1 was not capable of signing himself out, was confused and not in his right mind. In an interview on 10/24/25 at 11:23 a.m. the traveling DON said on an unknown date, a nurse saw CR #1 walking on the street. She said

she and the DON jumped in the car and went down the street to look for him. She said she saw him headed back towards the facility. She got out of the car and asked if he was ok. She said he told her he left the facility to look for his family member's house/apartment, he realized he did not know how to get there and was headed back to the facility. She said he had no injuries and was not in distress but felt bad he left and was apologetic for leaving and not saying where he was going. She said that was her last day working at

the facility and the DON had already taken over and was not working under her. She said she did not conduct any in-services with the staff. The DON and previous Administrator were in charge at the time. In

an interview on 10/27/25 at 9:10 a.m. LVN W said the incident with CR #1 occurred during change of shift and he was not assigned to CR #1 yet because CR #1 was not in the building. He said the previous Administrator made an announcement that CR #1 was missing and told everyone to go look for and find the patient. He said he searched around the building, in the trash cans and dumpster. He said a head-to-toe assessment was completed probably by the DON, but he was unsure. He said CR #1 sometimes heard voices in his mind and might have come up with the idea of meeting his family member at the local business. He said CR #1 could hold a basic conversation but anything in depth was not reliable because of his cognition, but he was cognitive enough to not injure himself or others. He said CR #1 was not one to sign himself out of the building and said he did not even know what that was. He said he was not told it was

an incident because CR #1 walked off and then walked back to the facility. He said the DON was the lead nurse and took over the documentation. Record review of Long-Term Care Regulation Provider Letter dated 8/29/24 provided by the facility read in part, ‘.2.1 Incidents that a NF must report to HHSC. A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: abuse, neglect. a missing resident.2.4 Reportable Incidents and Timeframes. Do Report: an incident that does not result in serious bodily injury but that involves any of the following: . a missing resident. when to report:. immediately, but not later than 24 hours after the incidents occurs or is suspected . Missing resident: example of a missing resident: A resident is not in his room when staff wake residents up in the morning and the bed appears not to have been slept in. Staff search the facility and cannot find the resident.

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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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Deerbrook Skilled Nursing and Rehab Center

9250 Humble-Westfield Rd Humble, TX 77338

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

residents at risk for elopement and ensure adequate supervision is in place. The Charge Nurse will routinely conduct every 2 rounds and document knowledge of residents' whereabouts throughout their shift

on an audit form. Any episode of elopement will be documented in the risk management system portal and notify the DON/Administrator immediately. The DON/designee will monitor the risk management system portal 3 times a week X 6 weeks and document findings on an audit report form. Quality AssuranceAn impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed

on 10/22/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 10/22/25, DON/Nurse Managers assessed all residents for elopement risks. No new residents were found to be affected. Training conducted with staff to immediately page code white over the paging system whenever it is deemed there is a missing resident, initiate a search throughout the inside of the facility and facility grounds. If the resident is still not located, extend search to the immediate neighborhood. If the resident is still not located within 30 minutes, notify the Police Department for further assistance to search for the missing resident. Training to be conducted during the orientation of newly hired staff (full-time, part-time, and PRN). The DON/designees to provide oversight and ensure compliance. No staff will be allowed to work without receiving the in-service on the regarding the elopement policy.Monitoring for implementation of the POR was conducted on 10/23/25 and 10/24/25:Record review of the facility's undated Off Cycle (ADHOC) QA meeting document read in part, .ADHOC QAAC for identification of a system in need of immediate attention by QAPI Committee was conducted and had 7 signatures. Record

review of the facility's Elopement Policy in-service dated 10/22/25 read in part, .Immediately

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

Deerbrook Skilled Nursing and Rehab Center

9250 Humble-Westfield Rd Humble, TX 77338

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

gloves in her pocket. CNA A stated it was not hygienic to keep gloves in pockets and it was not an encouraged habit. CNA A checked the doorway and stated she didn't know there was a box of extra large gloves available. CNA A stated she did clean Resident #1's penis by wiping with cleansing cloth twice. CNA

A stated she learned male peri care when she first stated working at the facility several months ago and had inservices on infection control and peri care for both male and female. CNA A stated she was supposed to perform hand hygiene prior to leaving Resident #1's room but got nervous. CNA A stated the risk of not doing hand hygiene was the germs from hands can get onto items touched and a resident could get infected if they touch the same items.In an interview on 10/27/25 at 12:30 PM, the DON stated she expected nursing staff to change gloves, sanitize or wash hands to prevent infection as much as possible any time they are working from a clean area to a dirty area such as during peri care. The DON stated the CNAs may have been rushing through their work and did not perform hand hygiene as she expected. The DON stated she expected the nursing staff to wash their hands, change gloves to help prevent UTI. The DON stated residents who have a long history of UTIs, and the elderly population are examples or residents who are susceptible to UTIs.Record review of the facility policy for Perineal Care, revised in December 2011, read in part: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.Steps in the Procedure.10. For a male resident.b. Wash perineal area starting with urethra and working outward.12.

Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place.18. Remove gloves and 19. Wash and dry your hands thoroughly.

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

Deerbrook Skilled Nursing and Rehab Center

9250 Humble-Westfield Rd Humble, TX 77338

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

order. Record review of the facility's undated job description for Certified Nursing Assistant read in part: .The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and car plan and as may be directed by your supervisors. Record review of the facility's undated job description for Certified Medication Aide read in part: .The primary purpose of your job position is to assist in the administering of medications to residents as ordered by the attending physician, under the direction of the attending physician, the nurse supervisor or charge nurse, and the Director of Nursing Services. The administration of medications shall be in accordance with established nursing standard's, the policies, procedures and practices of this facility and the requirements of this state.As a Certified Medication Aide, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

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

Deerbrook Skilled Nursing and Rehab Center

9250 Humble-Westfield Rd Humble, TX 77338

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

hygiene prior to leaving Resident #1's room but got nervous. CNA A stated the risk of not doing hand hygiene was the germs from hands can get onto items touched and a resident could get infected if they touch the same items.In an interview on 10/27/25 at 12:30 PM, the DON stated she expected nursing staff to change gloves, sanitize or wash hands to prevent infection as much as possible any time they are working from a clean area to a dirty area such as during peri care. The DON stated the CNAs may have been rushing through their work and did not perform hand hygiene as she expected. The DON stated she expected the nursing staff to wash their hands, change gloves to help prevent UTI. The DON stated residents who have a long history of UTIs, and the elderly population are examples or residents who are susceptible to UTIs.Record review of the facility's policy on Enhanced Barrier Precaution, effective date April 1, 2024 revealed in part: The policy outlines the guidelines and procedures to implement enhanced barrier precautions to prevent the spread of infectious diseases among residents and staff. Definitions, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EPB are indicated for residents with any of the following:.Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Dressing.Transferring.changing briefs.Device care or use.urinary catheter.Wounds generally include chronic wounds.examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds.Record review of the facility policy for Perineal Care, revised in December 2011, read in part: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe

the resident's skin condition.Steps in the Procedure.2. Wash and dry your hands thoroughly.Put on gloves.12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13.

Put on clean gloves and place new brief and secure in place.18. Remove gloves and 19. Wash and dry your hands thoroughly.Record review of the facility's policy for Using a Mechanical Lifting Machine, revised July 2017, read in part: .Lift Care: 1. Disinfect lift surfaces. 2. Wipe with a clean towel until dry.

Event ID:

Facility ID:

If continuation sheet