Health inspection·March 13, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #3's had a care plan to reflect the residents' weight loss. 2. The facility failed to ensure Resident #3's had a care plan to reflect his medication Ozempic that was prescribed from November 2024 through February 2025. These failures could place residents at risk of not receiving adequate care and services to improve their quality of life. Findings include: Record review of Resident #3's face sheet, dated 11/04/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), cerebrovascular disease (a condition that affects the brain's blood supply and blood vessels), chronic pain (persistent pain), gastro esophageal reflux disease (A digestive disease in which the stomach acid or bile irritates the food pipe lining), muscle weakness (decrease strength in the muscle), diabetes (high blood sugar), anxiety (persistent worry or fear) depression (a common mental health characterized persistent low mood, loss of interest and other symptoms that interferes with daily life) and hemiplegia (paralysis or weakness on one side). Record review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 12, which indicated he was cognitively aware. For ADL's Resident #3 required partial/ moderate assistance in the areas of oral hygiene, toileting hygiene, upper body dressing, and lower body dressing, was substantial/maximal assistance in shower/bathe self and putting on/taking off footwear. For weight loss, he had a 15 pounds weight loss in two months. Record review of Resident #3's care plan, dated 11/12/2024, reflected Resident #3 was care planned for the following: Focus: The resident has nutritional problems or potential nutritional problem r/t Diet (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 455682 Printed: 05/15/2026 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 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Afton Oaks Nursing and Rehabilitation Center 7514 Kingsley St Houston, TX 77087 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)