F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review the facility failed to ensure the resident's had the right to have reasonable
access to the use of telephone, including TTY and TDD services, and a place in the facility where calls
could be made without being overheard for 1 of 3 (Resident #1) residents reviewed for telephone use.
Residents Affected - Few
The facility failed to provide a place for Resident #12 to make telephone calls without being overheard.
This failure could place residents at risk of conversations being overheard and privacy right's not being
respected and could result in a decline in resident's psychosocial well-being and quality of life.
Findings include:
Record review of Resident #12, dated 01/14/2021, reflected a [AGE] year-old female who was admitted to
the facility on [DATE].
Record review of Resident #12's History and Physical, dated 01/28/23, reflected a diagnosis which included
depression (a common mental health condition characterized by persistent low mood, loss of interest or
pleasure in activities, and other symptoms that interfere with daily functioning.)
Record review of Resident #12's quarterly MDS , dated 10/23/24, reflected a BIMS of 15, which indicated
the resident was cognitively intact.
During interview with Resident #12 on 03/11/2025 at 10:30AM revealed Resident #12 said she called
friends or family on the phone at the nursing station she was told that was the only place to make a
telephone call or if you had a cell phone. Resident #12 said the facility did not have cordless phones to use
and most of the resident's conversations were heard by the nurses or anyone walking by. Resident #12 said
the residents only got 15 minutes due to the nursing staff needing to use the phone. Resident #1 said she
had not been offered any other phone to use in private. Resident #12 said he knew how to use the phone;
however staff would call the number for her. Resident #12 said she did not feel secure in her conversations
and speaking in an open area, and she knew the nurse could hear her conversation. Resident #12 said it
made her feel like she did not have any privacy.
During interview with the DON on 03/11/2025 at 11:20 AM, the DON said the nurse's station was the only
area for residents to use the phone. Many of the alert residents had their own personal cell phones. The
DON said unfortunately the facility did not have an area for the residents to use for privacy.
(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 5
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
03/12/2025
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 0576
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During interview with the facility Administrator on 03/11/2025 at 12:00 PM, the Administrator said the
residents were able to use the phone at the nurse's station or at the receptionist desk if need be. The
Administrator stated he had a phone by his office, or the residents could use the phone in the
Administrator's office, if needed, but as of now the facility did not have designated area for the resident to
use and the facility was currently working on designating the physician office into the resident's phone area.
The Administrator said the facility did not have a policy on resident phone use and privacy.
Event ID:
Facility ID:
675743
If continuation sheet
Page 2 of 5
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
03/12/2025
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.
**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 were stored and
labeled in accordance with currently accepted professional principles for 1 of 4 medication carts observed.
The facility failed to dispose of Levothyroxine 88 mcg blister pack with expiration date of 1/31/25 for
Resident #55 from 2 [NAME] nurse medication cart on 3/11/25.
This failure could place residents at risk of receiving expired medications or inaccurate dosage of
medication which could lead to resident not receiving full therapeutic benefits of a medication or possible
side effects.
Findings include:
Record review of Resident #55's face sheet, dated 3/11/25, revealed a [AGE] year-old male who was
admitted to the facility on [DATE]. Resident #55 had diagnoses which included Other Alzheimer's Disease
(progressive brain disorder that destroys memory and thinking skills), Unspecified Dementia (group of
symptoms affecting memory, thinking and social abilities) with Mood Disturbance, Schizoaffective
Disorder/Bipolar Type (Disorder with abnormal thought processes and an unstable mood), and
Hypothyroidism (Underactive Thyroid).
Record review of Resident's #55's quarterly MDS, dated [DATE], revealed a BIMS score of 12, which
indicated moderate cognitive impairment.
Record review of Resident #55's Order Audit Report, dated 3/12/25, revealed Levothyroxine Sodium Oral
Tablet Give 88 mcg by mouth in the morning was discontinued on 10/29/2024 at 7:59 p.m.
Record review of Resident #55's Order Audit Report, dated 3/11/25, revealed Synthroid Oral Tablet 100
mcg (Levothyroxine Sodium) Give 1 tablet by mouth in the morning was created 10/29/24 at 7:48 p.m. and
was an active order.
Record review of Doctor's Progress Note, dated 10/28/24, revealed start levothyroxine 100 mcg p.o. daily,
discontinue levothyroxine 88 mcg p.o. daily.
Record review of Resident #55's Location of Administration Report, for October 2024 printed on 3/12/25,
revealed Resident #55 was last administered Levothyroxine Sodium Oral Tablet 88 mcg on 10/29/24 and
was administered Synthroid Oral Tablet 100 mcg (Levothyroxine Sodium) on 10/31/24.
Record review of Resident #55's Location of Administration Report for March 2025, printed on 3/11/25,
revealed Synthroid Oral Tablet 100 mcg (Levothyroxine Sodium) was administered from 3/1/25 through
3/11/25.
Record review of Resident #55's Care Plan, printed 3/11/25, revealed has hypothyroidism and interventions
included: Give thyroid replacement therapy as ordered.
Observation on 3/11/25 at 9:22 a.m. of 2 [NAME] nurse medication cart revealed Levothyroxine 88 mcg
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675743
If continuation sheet
Page 3 of 5
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
03/12/2025
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
blister pack with expiration date of 1/31/25 for Resident #55 was found on 2 [NAME] nurse medication cart.
LVN A immediately removed the Levothyroxine 88 mcg blister pack from the 2 [NAME] nurse medication
cart.
During interview on 3/11/25 at 9:22 a.m., LVN A said Levothyroxine 88 mcg blister pack for Resident #55
was expired. LVN A said she went through the medication cart weekly to make sure there were no expired
medications, and the Levothyroxine 88 mcg blister pack must have gotten missed.
During interview on 3/11/25 at 2:11 p.m., ADON A said when a medication is discontinued the nurse or
CMA should take the medication off the cart. ADON A said the RN supervisor (RN A) on the weekend did
medication cart audits once a month.
During interview on 3/11/25 at 2:13 p.m., ADON B said cart checks for expired medications should be done
weekly. ADON B said she tried to look at the medication carts monthly. ADON B said the weekend
supervisor (RN A) checked the medication carts this past weekend. ADON B said the CMAs and nurses
were ultimately responsible for expired medications on their carts.
Attempted interview with RN A on 3/11/25 at 3:00 p.m. was unsuccessful.
Attempted interview with RN A on 3/11/25 at 5:20 p.m. the State Surveyor sent RN A a text message after
receiving voicemail from RN A to coordinate contact.
During interview on 3/12/25 at 8:59 a.m., LVN B said she checked the nurse medication cart for expired
medication on Saturdays which included blister packs.
During interview on 3/12/25 at 9:05 a.m., MA A said she checked the medication carts once a week for
expired medications which included blister packs.
During interview on 3/12/25 at 9:08 a.m., the Pharmacist said he performed medication cart checks
biweekly. Medication cart checks included checking for expired medications which included blister packs.
The Pharmacist said Levothyroxine may have been left on a medication cart in case they were adjusting the
resident's dose.
During interview on 3/12/25 at 10:15 a.m., Resident #55 said there was not anything wrong with him when
he was asked if he took a thyroid medication. Resident #55 said the facility would try to give him four or five
pills, but he refused to take them.
During interview on 3/12/25 at 10:23 a.m., MA B said she usually checked her medication cart for expired
medications two times a week on Tuesdays and Thursdays which included blister packs. MA B said the
nurse would also check the medication aide medication cart, but she was not sure how often.
During interview on 3/12/25 at 10:25 a.m., LVN C said she checked the nurse and medication aide
medication carts once a week which included blister packs usually on night shift.
During interview on 3/12/25 at 10:27 a.m., LVN D said she checked the nurse medication cart every other
weekend for expired medications. LVN D said she would check the top drawer of the medication aide
medication cart for medications like eye drops. The top drawer of the medication aide medication cart also
included the over -the-counter medications.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675743
If continuation sheet
Page 4 of 5
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
03/12/2025
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During interview on 3/12/25 at 2:30 p.m., Clinical Resources (who was acting as DON) said the nurses and
CMAs were to check the medication carts they were assigned weekly and as needed for expired
medications. Clinical Resources also said the pharmacy performed monthly checks to medication carts for
expired medications.
Record review of the facility's policy Storage of Medications with revision, dated April 2007, revealed The
facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be
returned to the dispensing pharmacy or destroyed.
Event ID:
Facility ID:
675743
If continuation sheet
Page 5 of 5