F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to have the resident's comprehensive care plan,
reviewed, and revised by the interdisciplinary team after each assessment, including both the
comprehensive and quarterly review assessments for 1 (Resident #27) of 6 residents reviewed for care
plan timing and revision.
The facility failed to review and revise the comprehensive care plan for Resident #27.
This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and
physical problems/issues.
Findings included:
Record review of Resident #27's face sheet revealed a [AGE] year-old male who was admitted on [DATE].
His diagnosis was dementia (a group of conditions characterized by impairment of at least two brain
functions, such as memory loss and judgment), and cerebral infraction (occurs because of disrupted blood
flow to the brain due to problems with blood vessels that supply it).
Record review of resident #27's Comprehensive MDS dated [DATE] revealed Resident #27 had a BIMs
score of 06 indicating the resident was severely cognitively impaired. The resident required extensive
assistance with two persons physical assist with bed mobility. He required total dependence and
one-person physical assistance for dressing, total dependence and two persons assistance for toilet use,
supervision, and setup for eating, and total dependence and two persons assistance for transfer. He also
requires total dependence and one-person assistance for personal hygiene.
Record Review of resident #27's care plan, revision date not listed, revealed Resident #27 was not care
planned for a low bed.
Record Review of Resident #27's care plan, revision date not listed, revealed Resident #27's was care
planned for falls that occurred on 7/21/2022, 7/24/2022, 9/15/2022, 4/07/2023, and 4/13/2023. His goals
revealed he will demonstrate the ability to ambulate/transfer without fall related injuries over the next 90-day
review period. The interventions revealed, place call bell/light within easy reach, remind [NAME] to call for
assistance before moving from bed-to-chair and from chair to bed. Respond promptly to calls for assist to
the toilet, footwear will fit properly and have non-skid soles, and provide reminders to use ambulation and
transfer assist devices.
Observation on 5/2/2023 at 10:55a.m., revealed Resident #27, lying down on a bed that was very low
(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 7
Event ID:
675495
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
675495
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Court
3830 Mustang Road
Alvin, TX 77511
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)
F 0657
to the ground. His legs were touching the ground and his diaper was hanging off him.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 5/2/2023 at 11:00a.m., with CNA A, said Resident #27 bed was low because he sometimes
hangs his legs off the bed, and it keeps him from hurting himself. She said Resident #27 moved a lot which
moved his diaper off him. She said Resident #27 had an indwelling catheter.
Residents Affected - Few
Interview on 5/4/2023 at 9:34a.m., with Charge nurse/LVN P, said Resident #27 reposition himself when he
was lying in bed. He said he will put his feet off the bed and when he was tired, he would put his feet back
up. He said the bed was low because Resident #27 is a fall risk.
Interview on 5/4/2023 at 1:32p.m., with LVN X, said whenever something has changed with a resident, it
was important to write it in the care plan. She said the plan of care is in place to make sure everything was
good with the resident. LVN X said she looked through the care plan and said the low bed for Resident #27
was not documented in his care plan. She said the nurse would usually tell her if they needed help with
something and she would help them with the care plan. She said all the licensed nurses are responsible for
putting things in the care plan. She said she edited and took things out of the care plan if it was no longer
needed or when she does their next assessment. She said a nurse never shared with her that Resident
#27's low bed needed to be documented in his care plan. She said the nurse working with Resident #27 on
the hall would inform her of any changes with Resident #27. She said the PCC, ADON, the unit manager,
and the treatment nurse does the care plans.
Interview on 5/4/2023 at 1:52p.m., the ADON, said the importance of having a care plan was so they know
how to care for the patient. She said anyone can go into the system and see what needed to be done for
the patient. She said they have 24 hours reports that they use to write information regarding the residents,
and they also use clinical notes and daily care guides on how to care for the residents. She said they have
morning meetings and discuss the things that were needed or added to the care plan. She said the MDS
was on top of things like that. She said if the nurses were lowering Resident #27's bed, it should be
documented in the care plan. She said it could be a risk of the patient being off the low bed and having a
risk for injury if it was not noted in the care plan. She said for accuracy of the care plans, it was normally
done as a team, to ensure everyone was on the same page. She said the care plan should be update
quarterly or as needed.
Interview on 5/4/2023 at 2:15p.m., with unit manager LVN Y, said she tried to keep Resident #27's catheter
on the bed, and if the bed is high, he will reposition himself and might pull the catheter. She said it was
safer for the catheter to be near the bed. She said she knows that it is a low bed because it is a particular
type of bed. She said Resident #27 has a low bed in his room.
Record Review of the facility's policy titled Patient Care Management System, revised on 11/2017 read in
part . Each care plan must be reviewed and updated by the interdisciplinary Care Plan team quarterly, upon
each change in condition and upon re-admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675495
If continuation sheet
Page 2 of 7
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
675495
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Court
3830 Mustang Road
Alvin, TX 77511
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide pharmaceutical services to meet the
needs of each resident for 3 of 5 residents (Resident #56, Resident #69 and Resident #72) reviewed for
pharmacy services.
- The facility failed to ensure that the 200 Hall Nursing Cart did not contain expired insulin pens for Resident
#56, Resident #69 and Resident #72.
This failure could place residents at risk of not receiving the therapeutic benefit of medications, uncontrolled
blood sugars and/or adverse reactions to medications.
Findings Included
Resident #69
Record review of Resident #69's Face Sheet dated 05/03/23 revealed, a [AGE] year-old female admitted to
the facility on [DATE] with diagnoses which included: dementia, muscle weakness and type 2 diabetes.
Record review of Resident #69's admission MDS signed 09/05/22 revealed, use of corrective lenses,
moderately impaired cognition as indicated by a BIMS score of 12 out of 15, supervision for most ADLs and
occasionally incontinent of both bladder and bowel.
Record review of Resident #69's undated Care Plan revealed, no care plan problem areas related to
citation. The care plan did not include diabetes.
Record review of Resident #69's Patient Medication Profile dated 05/03/23 revealed, HumaLOG Insulincheck blood sugar and follow sliding scale four times starting 03/17/23.
Resident #56
Record review of Resident #56's Face Sheet dated 05/03/23 revealed, an [AGE] year-old female admitted
to the facility on [DATE] with diagnoses which included: high cholesterol, pressure ulcer of the left heal and
type 2 diabetes.
Record review of Resident #56's Annual MDS signed 03/29/23 revealed, severely impaired cognition as
indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of
both bladder and bowel.
Record review of Resident #56's undated Care Plan revealed, problem- risk for high or low blood sugar
episodes secondary to diabetes; interventions- medication as ordered.
Record review of Resident #56's Patient Medication Profile dated 05/03/23 revealed, NovoLOG( Insulin
Aspart)- check blood sugar and follow sliding scale four times a day starting 06/30/22. Lantus Insulin- 30
units under the skin two times daily starting 05/01/23.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675495
If continuation sheet
Page 3 of 7
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
675495
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Court
3830 Mustang Road
Alvin, TX 77511
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)
F 0755
Resident #72
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #72's Face Sheet dated 05/03/23 revealed, a [AGE] year-old female admitted to
the facility on [DATE] with diagnoses which included: irregular heartbeat, nicotine dependence and
diabetes.
Residents Affected - Some
Record review of Resident #72's Annual MDS signed 03/04/23 revealed, moderately impaired cognition as
indicated by a BIMS score of 11 out of 15, occasionally incontinent of bladder, always continent of bowel
and supervision for most ADLs.
Record review of Resident #72's undated Care Plan revealed, no care plan problem areas related to
citation. The care plan did not include diabetes.
Record review of Resident #72's Patient Medication Profile dated 05/03/23 revealed, HumaLOG Insulincheck blood sugar and follow sliding scale under the skin four times day with start date 03/14/22. Lantusinject 10 units under the skin two times daily.
An observation and interview on 05/04/23 at 09:04 AM AM, inventory of the 200 Hall Nursing Cart with LVN
A revealed:
- 1 expired, open and in-use Insulin Lispro vial for Resident #69 with an open date of 03/28/23.
- Expired, open and in-use Insulin Aspart (NovoLOG) and Lantus Insulin vials for Resident #56 with an
open dates of 03/28/23.
- Expired, open and in-use Insulin Lispro and Lantus Insulin vials for Resident #72 with an open dates of
03/28/23.
LVN A said nursing staff are expected to check their carts daily as used for expired medications including
insulin. She said the insulin pens should only be used for 30 days once opened (04/27/23) so they were
expired and could no longer be used. LVN A said when insulin expires it loses it efficacy and use could
place residents at risk for uncontrolled blood sugars. She said she would reorder the medication and then
ask her ADON on the appropriate way to dispose of the expired insulin.
In an interview on 05/03/23 at 11:00 AM, the ADON said nursing staff are expired to check their carts daily
for expired medications. She said when insulin expires it is was not as effective so they should be discarded
in the drug disposal bin in the medication room. The ADON said the use of expired insulin could place
residents at risk of uncontrolled blood sugars.
Record review of the facility's policy titled 'Storage of Medications' revised 04/2007 revealed, 4- the facility
shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to
the dispensing pharmacy or destroyed.
Record review of the facility's policy titled 'Drug Destruction' dated 09/2013 revealed, expired medications
shall be removed and disposed of through monthly drug destruction.
Record review of the undated facility documents titled 'Medication Storage Review' revealed, check insulins
and remove those open >28 days, except Levemir 42 days and Ozempic is 56 days. Date open must be
on vial/pen, vial/pen must be in fully labeled bag/box/bottle.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675495
If continuation sheet
Page 4 of 7
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
675495
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Court
3830 Mustang Road
Alvin, TX 77511
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure drugs and biologicals used in the
facility were labeled in accordance with professional principles, and included the appropriate accessory and
cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (300 Hall
Nursing Cart and 400 Hall Nursing Cart) reviewed for medication storage.
- The facility failed to ensure the 400 Hall Nursing Cart did not contain medications without pharmacy labels
identifying the patients or medication administration instructions.
- The facility failed to ensure the 300 Hall Nursing Cart did not contain insulin pens without open dates.
This failure could place residents at risk of uncontrolled health conditions and adverse medication
reactions.
Findings Included:
400 Hall Nursing Cart
An observation and interview on [DATE] at 09:08 AM, inventory of the 400 Hall Nursing Cart with LVN B
revealed:
- An Enoxaparin Sodium (a blood thinner) 40 mg/0.4 ml Injection without a pharmacy label.
- A vial of Nitroglycerin (treatment of chest pain) 0.4mg tablets without a pharmacy label.
LVN B said nursing staff are expected to check their carts daily for inappropriately labeled medications. She
said all medications must have a pharmacy label with patient identifiers and prescription information. LVN B
said since the Enoxaparin and Nitroglycerine had no labeling there could not be used and must be
discarded in the drug disposal bin located in the medication room. She said the use of medications without
the appropriate labels could place residents at risk for med errors because of the potential to give the
medications to the wrong resident or administer the wrong dose.
300 Hall Nursing cart
Resident #51
Record review of Resident #51's Face Sheet dated [DATE] revealed, a [AGE] year-old male admitted to the
facility on [DATE] with diagnoses which included: repeated falls, anxiety disorder, high cholesterol and type
2 diabetes.
Record review of Resident #51's admission MDS signed [DATE] revealed, moderately impaired cognition as
indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and always incontinent of
both bladder and bowel.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675495
If continuation sheet
Page 5 of 7
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
675495
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Court
3830 Mustang Road
Alvin, TX 77511
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #51's undated Care Plan revealed, problem- risk of hyper or hypoglycemic
episodes secondary to diabetes; interventions- medication as ordered.
Record review of Resident #51's Patient Medication Profile dated [DATE] revealed, Insulin Glargine
(Lantus)- Inject 25 units under the skin one time daily starting [DATE].
Residents Affected - Some
Resident #8
Record review of Resident #8's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted
to the facility on [DATE] with diagnoses of: anxiety disorder, heart failure and type 2 diabetes.
Record review of Resident #8's Annual MDS signed [DATE] revealed, intact cognition as indicated by a
BIMS score of 15 out of 15, extensive assistance with most ADLs, and occasionally incontinent of both
bladder and bowel.
Record review of Resident #8's undated Care Plan revealed, Problems- risk of hyper or hypoglycemic
episodes secondary to diabetes. Medication: Lantus Insulin.
Record review of Resident #8's Patient Medication Profile dated [DATE] revealed, Tresiba- 20 units under
the skin one time daily starting [DATE].
An observation and interview on [DATE] at 09:14 AM inventory of the 300 Hall Nursing Cart with LVN C
revealed:
- An open an in-use vial of Insulin Glargine (Lantus) with pharmacy fill date of [DATE] for Resident #51 with
no open date.
- An open and in-use Tresiba Insulin Pen for Resident #8 with no open date.
LVN C said nursing staff are expected to check their carts daily as used for inappropriately labeled
medications. She said insulin pens/vials should be labeled with the date opened in order to track the
expiration date. LVN C said when insulin expires it could become less effective and since the insulin found
had no open date their expiration dates could not be determined so they must be discarded in the sharps
container after they were reordered. She said the use of expired insulin could place residents at risk of
uncontrolled blood sugars.
In an interview on [DATE] at 11:00 AM, the ADON said nursing staff are expected to check their carts daily
as used for inappropriately labeled medications. She said all prescription medications must have a
pharmacy labeled with patient identifiers and drug information. The ADON said all multi-dose insulin
containers [NAME] be labeled with the date opened in order to track their expiration since insulin could
become less effective once expired. She said any insulin containers without open dates or inappropriately
labeled medications must be discarded in the drug disposal bin located in the medication room since the
expiration dates or patient information are unknown. The ADON said the use of medications without
pharmacy identifiers or insulin containers with no open date could place residents at risk of uncontrolled
blood sugars and adverse reactions.
Record review of the facility's policy titled 'Storage of Medications' revised 04/2007 revealed, 3- drug
containers that have missing, incomplete, improper, or incorrect labels shall be returned to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675495
If continuation sheet
Page 6 of 7
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
675495
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Court
3830 Mustang Road
Alvin, TX 77511
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)
F 0761
the pharmacy for proper labeling before storing.
Level of Harm - Minimal harm
or potential for actual harm
Record review of the facility's policy titled 'Administering Medications' revised 04/2019 revealed, 12expiration/beyond use date on the medication label is checked prior to administering. When opening a
multi-dose container, the date opened is recorded on the container.
Residents Affected - Some
Record review of the facility's policy titled 'Labeling of Medication Container' revised 04/2019 revealed, 3labels for individual resident medications include all necessary information such as: resident's name,
prescribing physician, pharmacy contact information, the prescription number, the date the medication was
dispensed, and the directions for use.
Record review of the undated facility documents titled 'Medication Storage Review' revealed, check-multi
dose containers for date open on container( . vials/pens for injectable meds and diluent fluid vials). Date
open must be on vial/pen, vial/pen must be in fully labeled bag/box/bottle.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675495
If continuation sheet
Page 7 of 7