Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure an allegation of abuse was reported to State
Agency within 24 hours for 1 of 1 resident (Resident #11) reviewed for self-reporting abuse.
The facility did not report to the State Agency within 24 hours when an outcry of abuse was made by
Resident #11 during a group meeting.
This failure could place residents at risk of harm due to delays in reporting an allegation of abuse.
Findings included:
Record review of Resident #11's face sheet not dated revealed a [AGE] year-old female admitted on
[DATE]. Her diagnoses were Cerebral Infraction and COPD (airflow blockage).
Record review of Resident #11's quarterly MDS dated [DATE] revealed Resident #11 had a BIMS Score of
15 out of 15 indicating Resident #11 was cognitively intact. Resident#11 required assistance with bed
mobility, transfer, walk in corridor, toileting, dressing and personal hygiene with one person assist. She
required set up only for eating.
Record review of Resident #11's care plan initiated 3/19/2021 read in part . Problem: Resident #11 has
hearing deficit on both ears. Goal: dignity will be maintained, and Resident#11 needs will be met.
Intervention: Face Resident #11 when speaking .
During a group meeting on 4/26/23 at 2:30pm, Resident#11 said, I felt something hitting my leg and my
heart started pounding until the next day I was so afraid. Resident #11 said it was Med-Aide A who hit her
on the leg.
During an interview on 4/27/23 at 1:26pm, the ED said he was the Abuse Coordinator. He said he spoke
with Med-Aide A on 4/26/23. The ED said Med-Aide A admitted to tapping Resident #11 and Med-Aide A
said he may have been rough with Resident #11 when he tapped her leg. The ED said he considered the
act of being rough with a resident as abuse. The ED said he would open a grievance on 4/26/23 and open
an investigation on 4/27/23. He said his abuse investigation would include talking to other residents and
staff members. He said during the investigation he would place Med-Aide A on suspension while the
investigation was ongoing. The ED said the allegation of abuse should have been reported because
Resident #11 should not have been made to feel uncomfortable and afraid. The ED said abuse should be
reported to the State Agency immediately. The ED said the facility staff were in serviced for
(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 11
Event ID:
675663
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 0609
Abuse on 3/22/23.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 4/27/23 at 1:48pm with RDCL, he said he was aware of the abuse outcry on 4/26/23
involving Resident #11. He said Resident #11 felt the Med-Aide touched her feet and Resident #11 became
startled. He said Med-Aide A apologized to Resident #11. The RDCL said a grievance was opened to
document the abuse allegation. He said the ED interviewed Med-Aide A and Med-Aide A said Resident #11
voiced concerns that he was rough before med-pass in his attempt to wake her up. He said the plan was to
educate, counsel and give Med-Aide A written warning for his actions. He said what he would have done
when an outcry of abuse occurred was to ensure residents were safe and protected first. He said he would
ensure the perpetrator was immediately removed from Resident #11 and notify the abuse coordinator. He
said he would notify ED about the alleged perpetrator and the ED would suspend the employee
immediately while the investigation was ongoing. The RDCL said he would generate a report to the State
Agency immediately.
Residents Affected - Few
During a telephone interview on 4/27/23 at 3:32pm with Med-Aide A, he said he worked weekends at the
facility. He said the ED called him on 4/26/23 regarding the abuse allegation. Med-Aide A could not recall
the exact date of the incident. He said Resident #11 got startled when he woke her up by tapping Resident
#11's leg. The Med-Aide A said he immediately apologized to Resident #11 and Resident #11 was okay
with his apology. The Med-Aide A said he immediately went and told the charge nurse, but he could not
recall the name of the charge nurse. He said he was in-serviced on abuse around January 2023 but could
not recall the exact date. Med-Aide A said tapping Resident #11 on her leg was a form of physical abuse
because Resident#11 got scared.
Record review of the state on-line self-reporting website on 4/27/23 at 4:28pm revealed no record of
facilities self-report regarding outcry of abuse.
Record review of HHS Long-Term Care Regulatory Provider Letter Date Issued: July 10, 2019, read in part
.State and federal law requires an owner or employee of a NF who has cause to believe that the physical or
mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or
exploitation caused by another person to report the abuse, neglect or exploitation . NFs must report all
suspected or alleged incidents involving abuse immediately, but not later than 24 hours after the incident
occurs or is suspected . A NF must report these incidents to the HHSC CII section.
Record review of the facility's Abuse policy titled; Abuse Protocol dated 11/2016 read in part . The ED will
10. (a) immediately within 24 hours report to The Department of Aging and Disability services and other
appropriate authorities' incidents of Patient/Resident Abuse as required under applicable regulations and
regulatory guidance. 10. (b) immediately within 24 hours suspend the employee for an abuse allegation until
an investigation is completed .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 2 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure residents who were incontinent of
bladder received appropriate treatment and services to prevent urinary tract infections and to restore
continence to the extent possible for 1 of 5 residents (Resident #195) reviewed for incontinent care.
The facility failed to ensure CNA A and CNA B properly cleaned Resident #195 during incontinent care.
This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin
breakdown and a decreased quality of life.
Findings include:
Record review of Resident #195's admission face sheet revealed a [AGE] year-old female who was
admitted to the facility on [DATE]. Her diagnoses included anemia (a condition in which the body does not
have enough healthy red blood cells), type 2 diabetic mellitus (a lifelong (chronic) disease in which there is
a high level of sugar (glucose) in the blood) and pneumonia (A severe inflammation of the lungs in which
the alveoli (tiny air sacs) are filled with fluid).
Record review of Resident #195's Comprehensive MDS assessment, dated 04/19/23, revealed a BIMS
score of 15 out of 15, which indicated intact cognition. She required extensive assistance from one-person
physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and
bladder.
Record review of Resident #195's care plan, initiated on 04/08/2023 revealed the following:
Problem: Bowel Continence: Resident is always incontinent of bowel movement (no episodes of continent
bowel movements).
Goals: Incontinence will be managed by staff without evidence of skin break down over the next 90 days.
Interventions: apply moisture barrier to buttocks. Document when resident is incontinent. Use pads/briefs to
manage incontinence.
Observation on 4/26/23 at 2:20 p.m., revealed CNA A provided incontinent care for Resident #195 and
CNA B assisted. CNA A removed Resident #195s brief and tucked it under the resident's buttocks. CNA A
did not spread Resident #195's labia to thoroughly clean the area and the resident's urinary meatus.
In an interview on 4/26/23 at 2:35 p.m. with CNA A and CNA B, CNA A said she received training from
other CNAs on the floor upon hire. She said she should have asked Resident #195's to open her legs wider
to thoroughly clean before she placed the clean brief on her. She said there was feces on the wipe when
the state surveyor asked her to clean the resident again. She said the facility did not have a DON. CNA A
said She did not remember when the Unit Manager last spot checked her. CNA A said Resident # 195's
skin should had been cleaned and free from feces before the clean brief was applied.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 3 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
She said the failure placed the resident at risk for skin breakdown and infections. CNA A said she recalled
doing CNA competency checks for incontinent care at the time of hire. CNA B said she was the shower
aide and provided showers to the residents.
In an interview on 04/26/22 at 2:43 p.m., the DON (from the sister facility), She said the facility hired a DON
this week on Monday (4/24/23) who was in training at the corporate office today. She said in the interim she
was assisting as an RN at this facility. She said she expected staff to provide prompt and efficient
incontinent care to prevent complications of infection and cross contamination. She said CNAs competency
check offs/assessments were completed upon hire and every 6 months. She said facility provided weekly
hand washing in services to staff. She said she randomly spot check on staff when she came to this facility.
She said last time she was in the facility was 2 weeks ago for 2 days, 8 hours each for RN coverage.
Record review of the facility's Perineal Care Protocol (February 2022) revealed read in part: .Cleansing the
perineal area between showers or baths, helps prevent irritation, infection, and skin breakdown as well as
keeping the patient comfortable. Separate Labia with hand to expose urethral meatus. Use one stroke
method to clean front to back. Wash labia major and skin folds. Use one stroke method to clean front to
back .
Record review of Incontinent Care Skills Checklist for CNA A dated 4/27/23 at 7:15am revealed read in
part: .4. Separate Labia with hand to expose urethral meatus. Use one stroke method to clean front to back.
5.Wash labia major and skin folds. Use one stroke method to clean front to back .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 4 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 - Few
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, interviews, and record review the facility failed to ensure in accordance with State and Federal
laws, all drugs and biologicals were stored securely in locked compartments under proper temperature
controls and permitted only authorized personnel to have access to the keys for 1 (Resident #34) of 8
residents reviewed for storage of medications.
The facility failed to ensure Resident #34's medication was kept in a secure location. Resident #34 had
medicated ointment at the bedside.
This deficient practice could place residents at risk for loss of prescribed medications, resident's safety, and
drug diversion.
Findings included:
Record review of Resident #34's clinical record revealed a [AGE] year-old female admitted to the facility on
[DATE]. Her diagnosis included pressure ulcer, stage 3 (Injury to skin and underlying tissue resulting from
prolonged pressure on the skin), pneumonia (is an infection that inflames the air sacs in one or both lungs)
and dementia (for loss of memory, language, problem-solving and other thinking abilities that are severe
enough to interfere with daily life).
Record review of Resident# 34's Comprehensive MDS assessment, dated [DATE], revealed a BIMS score
of 13 out of 15, which indicated intact cognition. She required total dependence with toilet use, transfer and
bed mobility from 2 person assist. She required extensive assistance with dressing with one person. She
had unhealed pressure ulcers/injuries Stage 3 (wound with full thickness tissue loss).
Record review of Resident #34 Care plan dated [DATE] revealed:
Problems: (Resident#34) has an unstageable DTI to left heel [DATE] wound care md here. Area is now
stage 3.
Goals: (Resident#34's) pressure ulcer will improve and have no further skin breakdown.
Interventions: Treatment to pressure ulcer per physician order. Continued review of the care plan did not
reveal Resident #34 could keep the Santyl ointment at the bedside.
Record review of Resident #34's physician's order dated [DATE] revealed an order to apply Santyl to left
heel. Continued review of the physician's orders did not reveal an order to keep at the bedside.
Observation on [DATE] at 8:57a.m., revealed Resident #34 in bed. A tube of Santyl ointment was sitting on
a side table near resident's bed. Resident said, this is for my heel. I have a wound. Nurse might have left it
here.
Observation and interview on [DATE] at 8:59a.m., MA BB stated Resident #34 did not have a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 5 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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
physician's order to keep her Santyl at the bedside. She stated the medication was to be kept in the
medication room or on the medication cart. She stated Santyl required a physician's order to administer.
She stated it was the responsibility of nurses to make sure there were no medications at the bedside. She
continued and stated the risk of the medication at the bedside was that a visitor or someone who should
not have it could take it.
Residents Affected - Few
In an interview on [DATE] at 1:10 p.m., with the ADON/ Unit Manager, she said the floor nurses performed
treatments. She said leaving Med at bedside was safety hazard for the resident. Dementia resident can put
it on their mouth. She said it was the responsibility of all staff including the housekeeper when they were
cleaning the room to make sure there were no medications at the bedside.
In an interview on [DATE] at 2:43 p.m., the DON (from the sister facility) said residents were not allowed to
have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they
would also need a doctor's order. She said she was not aware of Resident #34 having meds at bedside.
Record review of facility's Medication Storage policy (undated) revealed read in part: .review all OTC Rx
meds and remove expired and DC'd meds The policy did not include med at bedside.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 6 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to obtain a hospice election form, hospice plan
of care, the physician certification and recertification specific to the terminal illness, and hospice medication
information form for 1 (Resident #38) of 1 resident reviewed for hospice care.
This deficient practice could place residents who receive hospice services at risk for receiving inadequate
end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.
Findings:
Record review of Resident #38's face sheet dated 4/27/2023 revealed an [AGE] year-old male admitted on
[DATE] with diagnoses of Senile Degeneration of the Brain (Mental Decline), Indwelling Urethral Catheter
(Urinary Catheter), Multiple Fractures of Ribs, Left Side (Broken Ribs).
Record review of Resident #38's April 2023 orders revealed he was admitted to hospice services on
9/15/2022 with a diagnosis of Senile Degeneration of the Brain.
Record review of Resident #38's clinical record dates 9/15/2022 to 4/25/2023 reflected no hospice election
form, hospice plan of care, physician certification and recertification specific to the terminal illness, or
hospice medication information form from Hospice A.
Record review of Resident #38's medical file dated 3/27/2023 to 4/24/2023 revealed no documentation of
any communication or coordination of care with the hospice company.
Record review of Resident #38's Hospice Sign In Sheet with dates 3/32/2023 to 4/24/2023 revealed no
hospice staff sign-ins since 3/27/2023.
In an interview on 04/26/23 at 9:51 am with Unit Manager, she said there was no paperwork from hospice
on Resident#38. She said she was responsible for requesting paperwork from the hospice company. She
said it was important to have the paperwork because it was a record of the resident's plan of care and led
to the continuity of care.
In an interview on 04/26/23 9:57 am with the DON, she said she could not explain why there was no
hospice documentation for Resident #38 on file. She said it was important for the follow-up of care so
facility staff understand what hospice was doing, for family involvement and coordination of care so
everyone could work together to meet resident needs.
Record review of facility's policy titled, Hospice Program dated 2017 read in part . Obtaining the following
information from the hospice .The most recent hospice plan of care specific to each resident .Hospice
election form .Physician certification and recertification of the terminal illness specific to each resident
.Hospice medication information specific to each resident .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 7 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain an infection control program
designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and
transmission of disease and infection for 3 of 8 residents (Resident #3, #4 and #17) reviewed for infection
control in that:
Residents Affected - Some
-MA BB did not wash or sanitize her hands before entering Resident #3 and #17's room to check their vital
signs.
-MA BB did not disinfect the wrist blood pressure monitor in between Resident #3 and #17 when checking
their vital signs.
- CNA A and CNA B stored dirty linens and soiled brief trash bags on the floor in Resident#195's room.
- The facility failed to date Resident #4's suprapubic catheter drainage bag according to their policy.
These failures could affect residents and place them at risk of cross contamination and blocked urinary
catheters.
Findings included:
Resident#4
Record review of Resident #4's Face Sheet revealed a [AGE] year-old male who was admitted on [DATE]
with diagnoses of Urinary Tract Infection (Harmful Bacteria in Urinary Tract), Vascular Dementia (Brain
Damage Caused by Multiple Strokes), Obstructive and Reflux Uropathy (Urine Cannot Flow), Hemiplegia
Left Side (Paralysis Left Side of Body), and Type 2 Diabetes (Body Does Not Produce Insulin).
Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS of 6 out of 15 indicating the
resident was cognitively severely impaired. Resident #4 required extensive assistance with bed mobility,
transfers, locomotion, dressing, and toileting with one person assist. Section H noted, indwelling catheter.
Record review of Resident #4s Care Plan dated 10/4/2022 to present read in part . Problem: At risk for
infection related to indwelling catheter. Has suprapubic catheter placed. Suprapubic catheter change q 2
weeks .Goals: will remain free of urinary tract infection during period of catheterization next 90 days
.Intervention: Change drainage bag.
On 4/25/2023 at 9:40 am Surveyor observed no date on resident #4's suprapubic catheter drainage bag.
In an interview on 4/25/2023 at 09:41 am with Medication Aide BB, she said they changed the Foley last
week because Resident #4's family member always asked for it to be changed so evening nurses changed
it. She said residents could get an infection if the Foley catheter was not dated and not changed out when it
was supposed to be changed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 8 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
In an interview on 4/25/2023 at 09:45 am with CNA C, she said she thought Resident #4's Catheter was
changed last week but she could not recall the date. She said the foley catheter could also get obstructed if
not changed out routinely, and the Resident #4 could get an infection.
In an interview on 4/25/2023 at 09:47 am with the DON, she said not having dates on the Foley catheters
could cause infection, especially if they did not know when it was last changed. She said if a catheter was
not changed out, there was a high risk for infection. She said the policy was to change the Foley once a
month and the bag twice a month. She said the policy said there had to be a date on it. She said nursing
staff failed when Resident #4s was not changed out. She said nurses had specific dates to change them,
and a date was put on them when admitted , so it got changed on the first and the 20th. She said if the
nurses do not read the orders, they are not doing their jobs.
Resident#17
Record review of Resident #17's admission face sheet revealed a [AGE] year-old female who was admitted
to the facility on [DATE]. Her diagnoses type 2 diabetics mellitus, hypertension and cognitive
communication deficit.
Record review of Resident #17's Comprehensive MDS dated [DATE] revealed a BIMS score of 15 out of 15
indicating intact cognition. Resident required extensive assistance from one-person physical assist for toilet
use, bed mobility and transfer.
Record review of Resident #17's Care plan dated 2/25/22 revealed the following:
Problem: Resident has a history of hypertension. Resident currently takes: hypertensive medication.
Goals: Resident's B/P will stay within their normal limits, will not have s/s of hyper/hypo tension over the
next 90 days.
Interventions: Monitor B/P, increase edema, dizziness, headache, chest pain, etc.-report abn's to MD.
Resident#3
Record review of Resident #3's admission face sheet revealed a [AGE] year-old female who was admitted
to the facility on [DATE]. Her diagnoses chronic kidney disease, dementia and hypertension.
Record review of Resident #3's Comprehensive MDS dated [DATE] revealed a BIMS score of 06 out of 15
indicating severely impaired cognitively. Resident required total dependence from one-person physical
assist for toilet use. Required extensive assistance from one-person physical assist for bed mobility and
transfer.
Record review of Resident #3's Care plan dated 05/11/2021 revealed the following:
Problem: Resident has a history of hypertension. Resident currently takes: hypertensive medication.
Goals: Resident's B/P will stay within their normal limits, will not have s/s of hyper/hypo tension over the
next 90 days.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 9 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 0880
Interventions: Monitor B/P, increase edema, dizziness, headache, chest pain, etc.-report abn's to MD.
Level of Harm - Minimal harm
or potential for actual harm
Observation on 04/25/2023 at 9:04a.m., revealed MA BB entering Resident #3's room with blood pressure
cuff. MA BB checked Resident #3's vitals without gloves on. MA BB came out of Resident #3's room without
washing or sanitizing her hands or the equipment. She then went to see Resident #17.
Residents Affected - Some
Observation on 04/25/2023 at 9:06a.m., revealed MA BB checking Resident #17's vitals with the same
equipment used on Resident #3 without washing or sanitizing her hands or the equipment.
In an interview on 04/25/2023 at 9:08a.m., MA BB said she was going room to room to check resident's
vitals so she could administer their morning meds. MA BB confirmed she did not sanitize the blood
pressure monitor or use gloves in between residents #3 and #17. She said she was the Activity
Director/Medical Records. She said usually there were 2 nurses and a Unit Manager assigned on the floor.
She said one nurse called in sick therefore, she was asked to pass the meds to 8 rooms starting from room
[ROOM NUMBER] through room [ROOM NUMBER] and room [ROOM NUMBER]. She said she had her
medication aide license either year 2008 or 2010. She said she had not done med pass in a long time and
was not aware the multiuse equipment had to be sanitized in between residents. MA BB said she received
training on infection control sometime last week. She could not recall the exact date.
Resident#195
Record review of Resident #195's admission face sheet revealed a [AGE] year-old female who was
admitted to the facility on [DATE]. Her diagnoses included anemia, type 2 diabetic mellitus and pneumonia.
Record review of Resident #195's Comprehensive MDS assessment, dated 04/19/23, revealed a BIMS
score of 15 out of 15, which indicated intact cognition. She required extensive assistance from one-person
physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and
bladder.
Record review of Resident #195's care plan, initiated on 04/08/2023 revealed the following:
Problem: Bowel Continence: Resident is always incontinent of bowel movement (no episodes of continent
bowel movements).
Goals: Incontinence will be managed by staff without evidence of skin break down over the next 90 days.
Interventions: apply moisture barrier to buttocks. Document when resident is incontinent. Use pads/briefs to
manage incontinence.
Observation on 4/26/23 at 2:20 p.m., revealed CNA A provided incontinent care for Resident #195 and
CNA B assisted. CNA A placed soiled brief in a clear trash and placed the bag on the floor next to
resident's foot of the bed. During care CNA B said the resident's sheet were soiled and needed to be
changed. CNA B placed soiled linens (fitted sheet, draw sheet and blanket) in a clear trash bag and placed
the bag on the floor near the foot resident's bed.
In an interview on 4/26/23 at 2:37 p.m., with CNA A and CNA B. CNA B said she was a CNA, but she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 10 of 11
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
675663
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Bend Healthcare Center
3010 Bamore Rd
Rosenberg, TX 77471
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
worked as a shower aide and was not assigned to work the floor. She said she did good as far as assisting
CNA A. She said she placed the dirty linens on the floor because it was in a plastic bag. She said she was
in serviced on infection control a month ago. She could not recall the exact date. CNA A said she placed the
soiled brief and trash on the floor because it was close. CNA A said, there was a trash can I should have
put the trash in that instead of putting it on the floor. She said this placed risk for cross contamination. She
said she was in serviced on infection control a month ago. She could not recall the exact date.
In an interview on 04/26/22 at 2:43 p.m., with the DON (from the sister facility) Surveyor explained the
observation of MA A doing med pass from earlier. MA A without washing/sanitizing her hands was going
room to room checking the residents' vitals including blood pressure. MA A said she was not aware that she
needed to wipe all multi use equipment between residents. The DON said by not washing hands and
sanitizing multi use equipment increases the risk of spreading infections and cross contamination. She said
MA A was a medication aide before she was an Activity Director and have worked as medication aide. She
said nothing should be left on the floor as it was at risk for cross contamination. She said the facility
in-serviced staff on infection control weekly.
Policy on Linen/trash storage were not provided on exit.
Record review of facility's Infection control policy (November 2017) revealed read in part: .1. The facility
must establish an infection prevention and control program (IPCP) that must include: a. A system for
preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all
patients, staff, volunteers, visitors, and other individuals providing services under a contractual agreement
based upon the facility assessment .
Record review of facility's in service to all staff on 03/07/23 on Infection Control revealed read in part:
.Standard Precautions: standard precautions are based on the principle that all blood, body fluids,
non-intact skin, and mucous membranes may contain infectious agents. Standard precautions include:
Hand -hygiene.
The use of personal protective equipment (PPE).
Appropriate handling of equipment used in the care of patients. Appropriate handling of laundry. Standard
precautions apply to everyone, regardless of suspected or confirmed infection status they are called
standard because they apply to everyone!
Record review of facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy (Revised
September 2022) revealed read in part: . Resident-care equipment, including reusable items and durable
medical equipment will be cleaned and disinfected according to current CDC recommendations for
disinfection and the OSHA bloodborne pathogen standard. Policy Interpretation and Implementation: 5.
Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable
medical equipment). 6. Reusable resident care equipment is decontaminated and/or sterilized between
residents according to manufactures' instructions. 7. Only equipment that is designated reusable is used by
more than one resident .
Record review of facilities policy titled, Indwelling Catheter-Male and Female dated 6/14/2006 read in part .
Date drainage bag .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675663
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F761 - Labeling of Drugs and Biologicals
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.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FAQ · About this visit
Common questions about this visit
What happened during the April 27, 2023 survey of Fort Bend Healthcare Center?
This was a inspection survey of Fort Bend Healthcare Center on April 27, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Fort Bend Healthcare Center on April 27, 2023?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.