Inspection visit

Health inspectionJune 27, 2024

Fort Bend Healthcare CenterCMS #6756632 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for one of two controlled medication count sheets (hall 100) reviewed for the shift-to-shift reconciliation. -The facility staff failed to follow their policy to perform shift counts/audits at shift change and complete the log. -The Controlled Drugs-Count Record for Hall 100 had blanks for previous shift counts/audits. -The blanks in the Controlled Drugs-Count Record for Hall 100 were filled in days later. LVN D, who filled in the blanks could not provide an explanation. The failures placed residents at risk for not having medications available in case of drug diversion. Findings include: Record review on 06/25/24 at 12:30 p.m. of the Controlled Drugs-Count Record for the Hall 100 medication cart revealed, in part .Signing below acknowledges that you have counted the controlled drugs on hand and found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug Administration Record (individual medication count sheets). Further review reveled there were six places on the sheet that were left blank: 06/20/24 'Nurse On 2:00 p.m. to 10:00 p.m.' 06/20/24 'Nurse Off 2:00 p.m. to 10:00 p.m.' 06/21/24 'Nurse On 2:00 p.m. to 10:00 p.m.' 06/21/24 'Nurse Off 2:00 p.m. to 10:00 p.m.' 06/21/24 'Nurse On 10:00 p.m. to 6:00 a.m.' (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: 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 06/27/2024 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 0755 06/22/24 'Nurse Off 10:00 p.m. to 6:00 a.m.' Level of Harm - Minimal harm or potential for actual harm Record review on 06/26/24 at 3:05 p.m. of the same Controlled Drugs-Count Record for the Hall 100 medication cart revealed the following 'blank' boxes were initialed as having been counted: Residents Affected - Few 06/20/24 'Nurse On 2:00 p.m. to 10:00 p.m.' 06/20/24 'Nurse Off 2:00 p.m. to 10:00 p.m.' 06/21/24 'Nurse On 2:00 p.m. to 10:00 p.m.' 06/21/24 'Nurse Off 2:00 p.m. to 10:00 p.m.' The initials in the boxes were those of LVN D. In an interview on 06/26/24 at 3:45 p.m. LVN D was asked when she initialed the boxes for the 06/20/24 2:00 p.m. to 10:00 p.m. shift counts. She replied, I initialed the them on Thursday the 20th. When LVN D was asked when she initialed the boxes for the 06/21/24 2:00 p.m. to 10:00 p.m. shift counts, she replied I initialed them on Friday the 21st. At that time the Surveyor presented the copies from the previous day that had blanks for those times. LVN D did not provide an explanation. In an interview on 06/26/24 at 4:00 p.m., the DON said the controlled medications should be counted by both nurses (oncoming and outgoing) each shift. In an interview on 06/26/24 at 4:11 p.m., the DON was presented with the copies of the Controlled Drugs-Count Record for the Hall 100. She said filling in the blanks was 'unacceptable.' At that time, the DON asked LVN D about the filled-in boxes. LVN D replied, I don't know about that. Review of the facility policy Management of Controlled Medications (09/11/09) revealed, in part, .Shift-to-Shift Count: 1. Controlled medications will be counted every shift change (scheduled or incidental) by an authorized staff member (RN/LVN/CMA) reporting on duty with an authorized staff member reporting off duty .6. Both the authorized staff member reporting off duty and the authorized staff member reporting on duty verify that the count of all controlled medications and Controlled Drug Receipt/Record/Disposition Form(s) are correct and sign the Controlled Medication Count Sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 2 of 6 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 06/27/2024 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure the medication error rate was not five percent or greater. The facility had an error rate of 6%, based on 2 errors out of 29 opportunities, which involved two of four residents (Resident #94 and Resident #38) and two of four staff (LVN B and RN A) observed during medication administration reviewed for errors. Residents Affected - Some -LVN B failed to administer Thiamine 100 mg tablet to Resident #94 because it was not available. -RN A failed to administer Metoprolol 50 mg to Resident #38. These failures placed residents in the facility at risk for inadequate therapeutic outcomes and decline in health. Findings Include: Resident #94 Record review of the Face Sheet (run time 06/27/24 at 5:12 p.m.) for Resident #94 revealed he was [AGE] years old and was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, chronic kidney disease, congestive heart failure, and hypertension. Record review of the Care Plan (undated) for Resident #94 revealed, in part, .give medications per order . Observation on 06/26/24 at 08:20 a.m. revealed LVN B at the medication cart in front of Resident #94's room. LVN B was looking at the computer screen for guidance on what medications to dispense. LVN B dispensed the following medications: 1 Multivitamin tablet 1 Folic Acid 1 mg tablet 1 Toprol 25 mg tablet 1 Pantoprazole 40 mg tablet 1 Potassium Chloride ER 20 meq tablet 1 Gabapentin 300 mg 1 Bumetanide 2 mg tablet 1 Eliquis 5 mg tablet 15 cc Lactulose 10mg/15cc After LVN B closed the medication cart, the surveyor asked her how many total medications she had. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 3 of 6 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 06/27/2024 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 0759 She answered Nine. LVN B entered Resident #94's room and administered the medications. Level of Harm - Minimal harm or potential for actual harm Record review of the June 2024 MAR for Resident #94 revealed an order for Thiamine HCl (vitamin B1) 100 mg (1 tablet) to be given daily. The scheduled time was reflected as 07:00 a.m. The medication had not been given during the medication pass observation at 8:20 a.m. Residents Affected - Some In an interview on 06/26/24 at 11:10 a.m. LVN B stated she did not administer the Thiamine HCl 100 mg tablet to Resident #94. She said it was not available in the medication cart at the time of the medication administration pass. She said that after she completed her medication pass, she went to the medication room to get the Thiamine 100 mg (over-the-counter medication). She said when she returned to administer the tablet to Resident #94, he had already been sent to the hospital for an increased ammonia level lab result. In an interview on 06/26/24 at 3:44 p.m., UM C said Resident #94 had left for the hospital at 10:00 a.m. that day. Resident #38 Record review of the Face Sheet for Resident #38 revealed she was [AGE] years old and was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, pain in right knee, artificial right knee joint, atrial fibrillation (abnormal heart rhythm), and hypertension. Record review of the MDS (ARD 05/24/24) assessment for Resident #38 revealed she scored 15 of 15 on the BIMS, indicative of intact cognition. Record review of the Care Plan (undated) for Resident #38 revealed, in part, .give medications per order . Observation on 06/27/24 at 6:32 a.m. revealed RN A obtained Resident #38's blood pressure (114/80 mmHg ) and heart rate (68 bpm). Observation on 06/27/24 at 07:16 a.m. revealed RN A at the medication cart in front of Resident #38's room. RN A was looking at the computer screen for guidance on what medications to dispense. RN A dispensed the following medications: 1 Tramadol 50 mg tablet 1 Pregabalin 75 mg tablet 1 Omeprazole 20 mg tablet 1 Vitamin D3 25 mg tablet 1 Multivitamin tablet 2 Acetaminophen 325 mg tablets 1 Aspirin 81 mg chewable tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 4 of 6 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 06/27/2024 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 0759 1 Docusate Sodium 100 mg capsule Level of Harm - Minimal harm or potential for actual harm After RN A closed the medication cart, the surveyor asked her how many total medications she had. She answered '8' and said she counted both Acetaminophen as one. RN A entered Resident #38's room and administered the medications. Residents Affected - Some Record review of Resident #38's Physician Orders for June 2024 revealed an order for Metoprolol Tartrate (Toprol) 50 mg to be administered daily. The scheduled time was reflected as 7:00 a.m. The order reflected the medication was to be held if the systolic blood pressure was below 110 mmHg, if the diastolic blood pressure was below 60 mmHg, or if the heart rate was below 60. The medication had not been given during the medication pass observation. Observation and interview on 06/27/24 at 11:50 a.m. revealed RN A was asked to review Resident #38's medications on her computer. RN A looked at the screen and stated she gave the following medications: Tylenol (acetaminophen) 325 mg 2 Omeprazole 20 mg '1' Multivitamin '1' Toprol 50 mg '1' Docusate Sodium 100 mg '1' Vitamin D3 '1' Pregabalin 75 mg '1' Tramadol 50 mg '1' Aspirin 81 mg '1' RN A said the medications added up to '9,' as she counted the two acetaminophen as one. Observation on 06/27/24 at 11:55 a.m. revealed RN A opened the medication cart and showed the surveyor the medication card for Toprol 50 mg for Resident #38. The tablets were bright pink in color. Observation and interview on 06/27/24 at 11:58 a.m. revealed RN A exited Resident #38's room. She said Resident #38 just told her she remembered receiving the Toprol. In an interview on 06/27/24 at 11:59 a.m. Resident #38 said I don't think it [Toprol] was in there because it is a pink pill and I didn't see it. I usually notice it because of its color. She said she did not take the Toprol for blood pressure, but because she had atrial fibrillation. She said she took it to control her heart rate. In an interview on 06/27/24 at 12:00 p.m. RN A said she did not give the Toprol if Resident #38's heart rate was below .(she did not complete the statement). She looked at her paper she had written (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 5 of 6 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 06/27/2024 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 0759 Resident #38's vital signs on. It reflected '68'. She said the parameter to hold was 'under 60.' Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 6 of 6

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Citations

2 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.

0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0759GeneralS&S Epotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.

FAQ · About this visit

Common questions about this visit

What happened during the June 27, 2024 survey of Fort Bend Healthcare Center?

This was a inspection survey of Fort Bend Healthcare Center on June 27, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Fort Bend Healthcare Center on June 27, 2024?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."

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

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·June 27, 2024