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Complaint Investigation

Sylan Shores Health And Wellness

November 24, 2025 · La Porte, TX · 3950 Underwood Rd
Citations 1
CMS Rating 1/5
Beds 124
Provider ID 676490
Healthcare Facility
Sylan Shores Health And Wellness
La Porte, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Sylan Shores Health and Wellness in La Porte, TX — inspection on November 24, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

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.

Facility ID:

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.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.