Sylan Shores Health And Wellness
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
assessment and care screening tool) dated 11/02/2025, Resident #6 did not have a BIMS score completed (a brief interview to gauge cognitive patterns) and was marked as rarely or never understood. Resident #3 had short and long-term memory problems and was marked as severely impaired with daily decision making. Resident #6 had no falls since admission/entry. Resident #6 required substantial/maximal assistance with toileting, personal hygiene and showering and required substantial assistance with mobility
in bed such as sitting to lying and bed-to-chair transfer.Record review of Resident #6's care plan dated 11/24/2025, he was not care-planned for the fall on 11/7/2025. Resident #6 was care-planned for a fall on 12/31/2024 with interventions including administering pain medication, resident being assisted back to bed per his request and therapy to screen resident. Resident #6 was care-planned for being at risk for falls r/t ataxic gait (unsteady walking pattern), confusion, incontinence, with interventions including anticipating and meeting the resident's needs, bilateral fall mat while resident was in bed and scoop mattress. Record
review of Resident #6's progress notes, on 11/07/2025 at 10:00 a.m., Resident #6 had an unwitnessed fall
in the hallway. Resident #6 was found on the floor with reason for fall not evident. Resident #6 had bruising
on his forehead and was sent to the ER.Record review of Resident #6's change in condition assessment,
on 11/7/2025 he had a fall. Resident #6 was observed with a large bump on left side of the forehead and would be going to the hospital for further evaluation. Resident #6 had general weakness. Observation and attempted interview with Resident #6 on 11/24/2025 at 4:00 p.m., he appeared to be sleeping in his room with rise and fall of his chest observed, well-groomed and in no apparent discomfort. Resident #6 was in a scoop mattress in a low bed. There were no odors or clutter in the room.Interview with MDS A on 11/24/2025 at 3:41 p.m., she said she was an LVN and in charge of care plans, and she did this by assessing the residents herself and reviewing nurse's notes. If a resident had a fall, the nursing team would discuss it. She would assist and see how the fall happened and how to prevent it going forward. MDS A's responsibility would also be to document the date and interventions in the resident's care plan, which would be done the following day, unless the resident was sent out which they would wait until they came back to document the fall. MDS A said she would look into Resident #3 and Resident #6's fall. Interview on 11/24/2025 at 4:38 p.m., MDS A said she updated the care plans. Interview with LVN M on 11/24/2025 at 3:53 p.m., she remembered Resident #3 had a fall in October 2025 and she was the nurse who did the initial assessment. LVN M said she informed Resident #3's hospice nurse and the resident had no injuries at the time. Interview with the Administrator and DON on 11/24/2025 at 4:30 p.m., the Administrator said Residents #3 and #6's falls should have been care-planned. If staff did not know how a resident fell, they would not know how to care for the resident. The MDS Nurses completed care plans, and the DON and regional nurses would monitor MDS nurses for compliance. The DON said there could have been negative outcomes to Residents' #3 and #6's falls not being care planned. The DON and Regional monitor the MDS Nurse to ensure care plans are completed. Record review of the facility's care plan process, undated and with reference to the CMS RAI Manual (Manual with instructions on filling out a resident's MDS) read in part, residents' preferences and goals may change throughout their stay, therefore the IDT should have ongoing discussions with the resident and resident representative, and staff member, so that changes can be reflected in the comprehensive care plan.
Event ID:
Facility ID:
If continuation sheet
Sylan Shores Health and Wellness in La Porte, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in La Porte, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Sylan Shores Health and Wellness or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.