Skip to main content

Inspection visit

Health inspection

BROOKDALE GALLERIACMS #6758341 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmaceutical services.LVN C failed to remain in the room and monitor Resident #1's Family Member A administer medications to Resident #1. This failure could place residents at risk of not receiving the therapy needed. Findings included:Record review of Resident #1's admission MDS Assessment, dated 11 /14/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included spinal stenosis, lumbar region without neurogenic claudication (degenerative condition characterized by the narrowing of the spinal canal in the lower back), hypertension (high blood pressure), diabetes mellitus (disease that occurs when blood sugar are too high), and anxiety disorder (feeling of fear, and uneasiness). Resident #1's BIMS score was not completed. Record review of Resident #1's Care Plan, dated 11/14/25, did not address medication administration. Observation on 11/18/25 at 9:22 AM, LVN C entered Resident #1's room, LVN C had a clear cup with pills inside. Resident #1's family member took the cup with pills and began to give Resident #1 pills 1 by 1. LVN C was observed checking Resident #1's blood pressure then blood sugars, once done checking LVN C was observed leaving the room before ensuring Resident #1 took all his medications. Resident #1's family member was observed still administering two pills after LVN C left the room. LVN C was observed to return to her med cart that was located at end of the hall by the nurse's station. Interview on 11/18/25 at 9:27 AM, Resident #1 was observed sitting in his chair. Resident #1 stated he was doing well, Resident #1's Family Member A stated she had just finished giving resident last 2 pills. Resident #1's Family Member A stated Resident #1 does better and will take all his medications when she gives them to the resident. Resident #1's Family Member A stated she ensures he takes them all. Interview on 11/18/25 at 10:46 AM, LVN C revealed she was the nurse assigned to Resident #1. She stated she provided Resident #1's morning medication. LVN C stated Resident #1's family member gives the pills to Resident #1 because he swallows them better when family member gives them to him. LVN C stated she left the room and returned to the room to ensure that all his medications were taken. She stated she had good communication with Resident #1's Family Member and the Family Member ensured her Resident #1 took all his medications. LVN C stated it was the metformin pill that was still in the cup when she left the room. She stated she should had stayed in the room to ensure all medications was taken. She stated the potential risk of not staying in the room to ensure all medications was given would be someone else taking the medications. Interview on 11/18/25 at 3:47 PM, Unit Manager D revealed nurses should follow the five rights of medication administration which were right patient, right drug, right dose, right route, and right time. She stated nurses should stay with the residents until all medications had been administered. She stated she was made aware of the situation (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 2 Event ID: 675834 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 675834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Galleria 2929 Post Oak Blvd Houston, TX 77056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with LVN C leaving the room. She stated it was a failure if the nurse left without ensuring all medications was administered. Unit Manager D stated the potential risk would be resident choking.Interview on 11/18/25 at 4:45 PM, the DON revealed all nurses should follow the five rights of medication administration. She stated all nurses should stay in the room to ensure all medications had been administered. She stated LVN C failed to ensure that the resident swallowed all his medications before leaving the room. The DON stated the potential risk would be anything could happen to the medication if left unattended. Record review of the facility's Medication Administration policy, revised May 2025, reflected the following: A. FOR ORAL MEDICATION ADMINISTRATION: . 7. Observe the client taking the medication. Event ID: Facility ID: 675834 If continuation sheet Page 2 of 2

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Back to top

Citations

1 citation 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.

FAQ · About this visit

Common questions about this visit

What happened during the November 18, 2025 survey of BROOKDALE GALLERIA?

This was a inspection survey of BROOKDALE GALLERIA on November 18, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BROOKDALE GALLERIA on November 18, 2025?

Yes, 1 deficiency was 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.

Share this reportEmail

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.