Oakmont Healthcare And Rehabilitation Of Humble

items are incorporated and updated in the care plan as needed.

She stated when there is a change in

Nurse, Rehab, DON, and ADMN is responsible for informing MDS and IDT of changes in a resident's

which may have contributed to the hand contracture not being adequately addressed in the care plan.

Failure to revise the care plan to include interventions for the contracture could result in the resident not receiving needed care and experiencing delays in services. In an interview with Interim DON on 02/26/2026 at 10:35am she stated she was not aware of Resident #69's left-hand contracture; however, the expectation is that nursing staff immediately report any observed change so the resident can be properly assessed. If the SBAR is not completed, the care plan cannot be updated, resulting in a missed opportunity to provide necessary care and placing the resident at risk. In an interview with ADON on 02/26/2026 at 2:50pm she stated SBAR is the assessment tool used to determine when the family and the physician must be notified. As soon as the change is observed, anything that is not the resident's normal status, staff are expected to report it immediately.

The SBAR provides real time guidance on what actions to take and how to process the change.

She is responsible for acute care updates and stated she revises care plans daily. ADON stated with every change in condition, the physician is notified, and each concern is evaluated promptly.

She is familiar with Resident #69's contracture, though she was not entirely aware of its extent, and noted that she would have updated the care plan or completed an assessment had the concern been communicated to her.

Failure to act on a change could lead to worsening symptoms or severe outcomes, which is why staff are expected to intervene early regardless of how the change presents.The facility policy for Change in Condition, Notifying the Physician of Change in Status undated, reads.This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nursewhen to notify the physician.1.

The nurse will notify the physician or their delegated nurse practitioner or physician assistant withchange in status.

The nurse will document signs and symptoms of significant change, time/date of callto physician, and interventions that were implemented in the resident's clinical record.8. If the resident remains in the facility and a significant change has occurred, update the care planaccordingly.

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Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

member to another hall.

She stated a few days later Resident #71 came up to her and implied during

She stated the resident's face was asymmetrical so the right side of her face was slightly larger than

resident was unable to wear her dentures due to swelling to the right side of her face.

When asked if she reassessed the resident, she stated she did not because she had already assessed the resident and the resident's face was asymmetrical.

She stated she informed the abuse coordinator, which was the administrator, of the incident.

She stated out of an abundance of caution, the Administrator informed her that the resident get an X-Ray due to the resident's previous allegations against other staff members and because the resident complained of swelling to her face.

She stated the resident's X ray results came back negative.

She reiterated that when she observed the resident her face was not swollen, the resident's face was asymmetrical and that the resident did not complain of pain.

She stated she did an in-service with CNA JK. In an interview on 02/26/2026 at 3:30PM with CNA JL she stated Resident #71 was a 2 person assist.

She stated she recalled doing a 2 person assist with CNA JK for Resident #71.

She stated she was standing on the window side and CNA JK was standing on the opposite side and they were turning the resident like normal.

She stated Resident #71's face was towards the nightstand, and it was close to the nightstand, but it never touched the nightstand.

She stated Resident #71 never said anything to her about her face being pressed up against the nightstand and she never complained of any pain.

She stated she never observed Resident #71's face being swollen or any lumps. In an interview on 02/26/2026 with the Administrator at 3:45PM, she stated the former DON stated she did a one on one with CNA JK (ensuring she was gentle and respectful to the resident while performing incontinent care and customer service).

She stated she was unable to provide the documentation from the in-service due to the former DON taking items with her when she was terminated.

Record review of Resident #71's Xray findings dated 01/09/2026 revealed views of the facial bones demonstrated no acute fracture or dislocation.

Record review of facilities undated Resident Rights policy revealed; Safe Environment.

The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. a. a.

This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.On 02/26/2026, a Policy for Accidents/Supervision was requested and the Administrator reported the facility did not have a policy as such.

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Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

out. LVN G stated Hospice services were in Resident #6's room earlier in the day and maybe took the

correctly by physician orders and that she expected the nurses to monitor settings every shift to

should be followed.

The Interim DON stated the risk to a resident was potential shortness of breath.

The Interim DON stated Hospice services was with Resident #6 on 2/24/26 and on 2/25/26 and may have set the oxygen to 4L/m.

Record review of the facility's undated policy for Oxygen Administration read in part: .Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems.

The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician.

The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse.

solution 250 mg/5 mL give 3 mL via g-tube three times a day for seizure, order date 8/13/25.In an

Resident #28's room and began medication administration via g-tube to Resident #28. LVN D checked

in between each one.

After administering the last medication, she flushed the tube with 30 mL of water. LVN D said she forgot the water flush in between the medications and said she did not have an order to flush with water in between the medications.

After completing the medication pass, LVN D exited the room and began to document the medication administration on the computer.

She reviewed the medication orders for Resident #28 and when the order for flush enteral tube with at least 10 mL of water between each medication appeared, she said she got nervous and forgot to flush between each medication. In an interview on 2/26/26 at 10:22 a.m. the interim DON said medications should be given per order.

She said nursing staff should ensure they review the physician order from the eMAR to ensure the medication matches and is provided at the right time.

She said the PM timeframe was scheduled from 6:00 p.m. - 10:00 p.m.

She said g-tube medications should be flushed per the MD order and the purpose of the water flush in between medications was to ensure all medication has gone through the tubing. In an interview on 2/26/26 at 11:34 a.m. the Administrator said she expected the medication error rate to be 5% or less.

She said medication passes were a part of the rapid response team.

Record review of the facility's Medication Administration and General Guidelines dated 2025 read in part, .Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so.

Medications are administered in accordance with written orders of the attending physician. 6.

All current medications and dosage schedules, except topicals used for treatments, are listed on the resident's medication administration record (MAR). 10.

Medications are administered within one hour of the scheduled time, unless the physician specifies a specifictime then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise).

Before or after meal orders are administered precisely as ordered.

Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility.

Checklist for completing proper steps in the administration of medications.

Adheres to the 6 Rights of Medication Administration.5) Right Time.

Record review of the facility's Enteral Tube Medication Administration dated 2025 read in part, .The facility assures the safe and effective administration of enteral formulas and medications. 7.

Read medication label three times before administering, checking with MAR.Administer each medication separately, flushing tube with 5-15 ml of water after each dose.

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Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338