Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text
for Tag 0584, Regulation FF11
Residents Affected - Few
[NAME], [NAME] R.
Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary,
and comfortable environment for residents, staff, and the public for 1 of 2 rooms (room [ROOM NUMBER])
reviewed for safety and sanitation in that:
Resident room [ROOM NUMBER] window blind was broken, overhead lamp was missing one light bulb,
wall near the headboard had and exposed wall electrical socket, and the wall near the headboard had
numerous scratches and damage to the sheet rock.
These failures could place the residents at risk for a diminished quality of life.
The findings included:
Observation on 9/28/22 at 11:00 AM of room [ROOM NUMBER] revealed: broken window blind, wall near
bedside headboard had exposed plaster and electrical wall socket was not covered with plaster. The wall
behind the bed board needed painting and repairs due to numerous scratches to the sheetrock. There was
a missing light bulb in the overhead light lamp.
During an interview on 9/28/22 at 11:00 AM, Resident #49 in room [ROOM NUMBER] was alert and not
oriented and could not provide any responses to direct questions involving the physical environment of the
room.
During an interview on 9/28/22 at 11:01 AM with the DON, she revealed that, there was a broken window
blind, wall near bedside headboard had exposed plaster and electrical wall socket was not covered with
plaster. The wall behind the bed board needed painting and repairs due to numerous scratches to the
sheetrock. There was a missing light bulb in the overhead light lamp. The DON also revealed that staff
assigned to Angel Rounds were responsible to check on the environment and submit work orders to the
Maintenance Director. [She provided no explanation for the environmental issues found in room [ROOM
NUMBER].]
During an interview on 9/28/22 at 11:14 AM with the Maintenance Director, he stated the walls and window
screens should not be that way .it is their (residents' homes) .staff making rounds have not reported these
issues noticed in room [ROOM NUMBER] to me . He stated that the window blinds would be
(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:
675743
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
675743
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Phoenix Post-Acute
519 Ninth Ave N
Texas City, TX 77590
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
immediately replaced with a new one. The wall would be repaired and painted. The Maintenance Director
revealed there was no overall maintenance policy instead the facility used the TELS (technology-based
system for delivering life safety) computer system for monitoring the maintenance of the facility. The
Maintenance Director was responsible for the environmental safety and repair of the facility.
During an interview on 9/28/22 at 12:23 PM with the Administrator, he revealed that facility had a guardian
angel round system where the environment was checked every day and work orders were sent to the
Maintenance Director for repairs; and environment issues were discussed at morning meetings. The
Administrator added that he made environment rounds in the morning and evening. The Administrator
stated that he had no excuse for the environmental issues found in room [ROOM NUMBER]. The
Administrator revealed there was no overall maintenance policy instead the facility used the TELS computer
system for monitoring the maintenance of the facility. The Administrator revealed that he expected staff
assigned as Guardian Angels to observe the homelike and physical appearance of rooms and to report
needs for repair to the Maintenance Director.
Record review of facility Unit log for the month of September 2022 did not reveal a work order for room
[ROOM NUMBER].
Record review of facility's Guardian Angel round assignments revealed Guardian Angels rounds were
documented for the month of September 2022; no information documented on the environmental issues in
room [ROOM NUMBER]
Record review of facility's policies, some dated and others not dated, did not reveal an overall policy on the
maintenance of the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675743
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
675743
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Phoenix Post-Acute
519 Ninth Ave N
Texas City, TX 77590
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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
interviews and record review the facility failed to develop and implement a comprehensive person-centered
care plan for each resident, consistent with the resident rights and that includes measurable objectives and
timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in
the comprehensive assessment for 3 of 8 (Resident's #13, #43, #194) residents with advanced directives in
that:
1. Resident #13's advanced directive of full code was not care planned.
2. Resident #43's advanced directive of full code was not care planned.
3. Resident #194's advanced directive of full code was not care planned.
This failure could place all residents that had a right for advanced directive and could result in
misunderstandings with the staff on residents' choices.
The findings included:
1. Record review of Resident #13's face sheet dated 9/30/2022 revealed he was admitted on [DATE] and
re-admitted on [DATE] with diagnoses of acute osteomyelitis, left ankle and food, diabetes II, major
depressive disorder, abnormal posture, chronic obstructive pulmonary disease, renal dialysis and included
a full code advanced directive.
Record review of Resident #13's 5-day MDS (minimum data set) revealed section C Cognitive Patterns was
a 11/15 on his BIMS score, indicating cognitively intact.
Record review of Resident #13's care plan dated 8/1/2022 revealed no care plan for advanced directive.
Interview on 9/29/2022 at 3:02 PM with the SW stated, she did not see the advanced directive for Resident
#13 in his care plan. The SW stated the interdisciplinary team meeting were responsible for resident care
plans. The SW stated that each discipline needed to input information about resident.
2. Record review of Resident #43's face sheet dated 9/30/2022 revealed she was admitted on [DATE] and
re-admitted on [DATE] revealed her diagnoses was iron deficiency anemia, muscle wasting and atrophy,
dysphagia following cerebral infraction, acute kidney disease, diabetes II, major depressive disorder and
included a full code advanced directive.
Record review of Resident #43's care plan dated 9/26/2022 revealed no care plan for advanced directive.
Record review of Resident #43's [NAME] MDS dated [DATE] revealed section C Cognitive Patterns was a
05/15 on his BIMS score, indicating severely impaired.
Interview on 9/29/2022 at 3:27 PM with the SW, she stated she did not see Resident #43's advanced
direction full code in her care plan.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675743
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
675743
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Phoenix Post-Acute
519 Ninth Ave N
Texas City, TX 77590
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
3. Record review of Resident #194's face sheet dated 9/30/20222 revealed he was admitted on [DATE] and
re-admitted on [DATE] with diagnoses of diabetes II, chronic obstructive pulmonary disease, major
depressive disorder, encephalopathy, and included an advanced directive of full code.
Record review of Resident #194's significant change MDS dated [DATE] revealed section C Cognitive
Patterns indicated he was severely impaired.
Record review of Resident #194's care plan dated 9/3/2022 revealed no care plan for advanced directive.
Interview on 9/29/22 at 3:35 PM with the SW, she stated she did not see Resident #194's advanced
directive full code in his care plan.
Interview on 9/29/2022 at 4:19 PM, the Administrator stated the SW, and the IDT team were responsible,
for ensuring the resident care plans had advanced directive of resident choice and right.
Record review of the facility Policy on Advanced Directives for Car Plan review dated 7/2017 revealed It is
the policy of this facility to inform each resident upon move-in, of their right to implement Advanced
Directive. 4 A copy of each residents' Advance Directive will be kept in the resident's medical record.
Comprehensive person-centered care planning- A initial goals based on admission orders, E-Social
Services, Comprehensive care plans-The facility must develop and implement a comprehensive
person-centered care plan for each resident, consistent with the resident rights and that includes
measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial
needs that are identified in the comprehensive assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675743
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
675743
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Phoenix Post-Acute
519 Ninth Ave N
Texas City, TX 77590
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.
Based on observations, record review, and interviews, the facility failed to store all drugs and biologicals in
locked compartments in 1 of 8 medication storage carts (2nd Floor East Wing Nurses' Medication Cart)
observed for drug security in that:
The 2nd Floor East Wing Nurses' Medication Cart was left unattended and unlocked in the pass-through
area between the common dining and activities area and the hallway to resident rooms.
This failure could place all residents who have medications in the 2nd Floor East Wing Nurses' Medication
Cart at risk for lost medications, drug diversion, or harm due to accidental ingestion of unprescribed
medications.
The findings included:
In an observation on 9/27/22 at 12:31 PM, the 2nd Floor East Wing, the Nurses' Medication Cart was
observed unlocked and unattended in the pass-through area. The medication cart was full; contained many
prescription and over-the-counter medications for a multitude of residents. This area was used by all staff,
residents, and visitors as means to access the main common area that included the dining and activities
area to resident rooms. Staff, residents, and visitors were observed in the immediate area.
In an interview on 9/27/2022 at 12:31 PM, LVN B stated the cart was unlocked and unattended. LVN B
stated the cart was her responsibility. LVN B stated it was the facility policy not to leave carts unlocked. LVN
B stated she did not intend to leave it unlocked. LVN B stated, she had left it unlocked when she was
distracted obtaining supplies per resident request (a straw during mealtime). LVN B stated it had been left
unlocked and unattended for less than 5 minutes. LVN B stated a negative outcome could occur if a
medication were ingested inappropriately by any person.
In an interview on 9/27/2022 at 4:30 PM, the DON stated medication carts were to be secured at all times
when not actively in use. The DON stated staff responsible for medication carts, such as nurses and
medication aides were trained not to leave the carts unlocked when not in use. The DON stated she had
already started an In-servicing to all staff on duty that might be responsible for a medication cart.
Record review of an undated policy entitled Medication Storage in the Facility, revealed the policy was
medication and biologicals are stored safely and securely. Procedures included: b.) Medication rooms,
carts, and medication supplies are locked or attend by persons with authorized access.
In a record review of an In-service Attendance Record dated 9/27/2022 with a subject of Medication carts
should be locked when not in use. Narcotics should be locked behind two key access. Included the above
policy on Medication Storage in the Facility and 5 staff signatures.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675743
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
675743
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Phoenix Post-Acute
519 Ninth Ave N
Texas City, TX 77590
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 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record reviews the facility failed to dispose of garbage and refuse
properly for 2 of 2 dumpster's reviewed in that:
Residents Affected - Some
Two of the dumpster side doors were open.
This failure could place residents at risk for infection and a decreased quality of life due to an exterior
environment which could attract flying pests, rodents, and animals.
The Findings included:
Observation on 9/27/2022 at 9: 14 AM of the outside of the kitchen area revealed 2 dumpster side doors
were open.
Observation on 9/28/2022 at 11:31 AM of the outside of the kitchen area revealed 2 dumpster side doors
were open.
Interview on 9/28/2022 at 11:33 AM with the Dietary Manager, stated dumpster 1 and 2 side doors were
open. The dietary manager stated all staff come out to dump garbage but forget to close the side doors. He
stated he will in-service staff to make sure the dumpster doors are closed.
Record review of the facility policy Environmental Services (no date) revealed All garbage will be disposed
of daily and as needed throughout the day. 1. if waste container is the type with doors, doors should remain
closed if not in use. 2. All dumpsters' lids and doors shell be closed .at all times.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675743
If continuation sheet
Page 6 of 6
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Back to topCitations
5 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.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
FAQ · About this visit
Common questions about this visit
What happened during the September 30, 2022 survey of THE PHOENIX POST-ACUTE?
This was a inspection survey of THE PHOENIX POST-ACUTE on September 30, 2022. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE PHOENIX POST-ACUTE on September 30, 2022?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
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 . If you believe any information is inaccurate, report it here.