Sylan Shores Health And Wellness
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
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.
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