Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to treat each resident with respect and dignity
and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 4
of 4 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for resident rights.
The facility failed to ensure staff assisted Resident #1, Resident #2, Resident#3 and Resident #4, by failing
to answer call lights in a timely manner to provide assistance.
This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase
anxiety.
The Findings include:
1. Record review of Resident#1's Face Sheet revealed an [AGE] year-old female admitted to the NF on
7/16/2024 with a diagnosis of hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm),
type 2 diabetes (body unable to produce insulin).
Record review of Resident#1's Baseline MDS assessment dated [DATE] did not reveal a BIMS score nor
was there an indication of resident's cognitive level.
Record Review of R#1's Care plan dated 7/16/2024 revealed resident was totally dependent on staff for all
her ADL's and staff was to ensure the call light is within reach.
On 7/31/2024 at 9:25 am, during an observation of Resident #1 revealed, she was lying in bed awake. She
appeared clean. Her face and hands were not dirty. Her hair was clean. Her call light was on her bed.
Observed the commode to be clean without any body fluids. During the attempted interview with Resident
#1 who was asked if she could answer a few questions, but she only stared and would not respond.
Resident #1's RPOA-A stated Resident #1 didn't feel like talking, but there were some concerns regarding
care and cleanliness. RPOA-A stated Resident #1 told him the room had not been cleaned at all on Sunday
and Monday. RPOA -A stated he came to the facility yesterday (7/30/2024) evening with a meal during
evening mealtime. He stated he personally observed the unclean RM and feces on the floor by Resident
#1's bed. RPOA-A stated they were not able to eat because to assist Resident #1 to sit up in bed to eat,
would have place him a position to step in the feces that was on the floor by her bed. RPOA -A stated the
Commode (bedside toilet seat), which was positioned approximately 3-4 feet from Resident #1's bed, had
not been emptied and was full of urine and feces. RPOA -A stated Resident #1 informed him when using
commode and wiping afterwards, Resident #1's hand would be dirty of the feces because of the toilet paper
filled to the top of the commode for her continuous usage and
(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 10
Event ID:
676258
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
no one to clean. RPOA -A was informed by Resident #1 that no one answered her call button for
assistance, and she tried to get to the commode by herself. However, she had an accident and used the
bathroom on the floor. RPOA -A complained, and housekeeping came and cleaned it up. Afterwards they
were able to eat the evening meal he came with. RPOA -A did not take any photos.
1. Record review of Resident #2's Face Sheet dated 7/26/2024 revealed a [AGE] year-old male with a
diagnosis of Rhabdomyolysis (breakdown of muscle tissue), acute kidney failure, hypothyroidism(thyroid
gland does not produce enough thyroid hormone).
Record review of Resident #2's baseline MDS dated [DATE] did not reveal a BIMS score nor was there an
indication of resident's cognitive level.
Record Review of Resident #2's Care plan dated 7/24/2024 revealed Resident #2 had bowel incontinence.
Check resident every two hours and assist with toileting as needed; provide bedpan/bedside commode;
provide pericare (washing genitals and anal area) after each incontinent (no control over bowel movement
or urination) episode.
On 7/31/2024 at 9:40 am, during an observation , Resident #2 was lying in bed, covered and asleep. There
was an IV being administered and his call light on his bed. He appeared clean and shaven. There was no
attempted interview as Resident was sleeping. Resident #2's RPOA-B was standing next to the bed and
had some concerns regarding staffing and cleanliness.
In an interview on 7/31/2024 at 9:45 am with RPOA-B revealed some concerns regarding Resident #2's
care. RPOA-B stated a FM wrote an email to the HR Department of the facility voicing concerns for the lack
of urgency when the call light is pushed. She states it takes over 30 minutes for staff to answer the call
lights.
2. Record Review of Resident #3's undated Face sheet revealed a [AGE] year-old male admitted to the NF
on 7/10/2024 with a diagnosis to include type 2 Diabetes Mellitus (body doesn't produce enough insulin),
Hypertension (high blood pressure) and Poly-osteoarthritis (arthritis in five or more joints at the same time).
Record review of Resident #3's MDS dated [DATE] did not reveal a BIMS score nor was there an indication
of resident's cognitive level.
Record Review of Resident #3's Care plan dated 7/10/2024, revealed Resident #3 was at risk for falls r/t
weakness The interventions were staff are to be sure call light was within reach and encourage the resident
to use it for assistance as needed. The resident needs prompt response to all request for assistance.
In an Interview on 7/31/2024 at 9:50 am with Resident #3 regarding call lights he stated most times the call
button goes unanswered and when it is answered, the normal response time is over 30 minutes. Resident
#3 states a dissatisfaction with the nursing service.
3. Record review of Resident #4's Face Sheet revealed a [AGE] year-old male admitted to the facility
7/24/2024 with a diagnosis of Epilepsy (Seizures) and Todd's Paralysis (temporary paralysis after epilepsy),
hypertension (high blood pressure), schizoaffective disorder (hallucinations and delusions).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676258
If continuation sheet
Page 2 of 10
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of R#4's MDS dated [DATE] did not reveal a BIMS score nor was there an indication of
resident's cognitive level.
Record Review of Resident #4's Care plan dated 7/24/2024 reveals Resident #4 was at risk for elopement
(Leaving the facility without permission or proper discharge) and adverse drug reaction (unintended events
attributed to the use of medicines).
In an interview on 7/31/2024 at 10:00 am, Resident #4 stated the response time for a call button response
is about an hour. He states night shift does not respond at all.
4. Record Review of Grievances listed below revealed concerns in achronological order:
5/15/2024 Resident complained about not being immediately changed. Staff terminated.
5/29/2024 Resident alleged a CNA was rude to him when he told her he needed to use his urinal. Resident
was told he could just use his brief. CNA removed from the schedule permanently. Staff in-service on abuse
& neglect and customer service.
7/21/2024 Resident alleged call light is on for 1hr & a half and nebulizer was on window seal out of reach.
Resident state she couldn't get her nebulizer for over an hour. Facility went over resident medications.
Customer service for night shift staff and notified.
7/21/2024 Resident alleged during the 11p-7a shift call lights were on 2hrs. Stated staff changed briefs, but
resident told to wait for bed linen to be changed on 7a-3pm. 7/22/224 Facility staff listened to concerns,
discussed plan of care regarding briefs, shower schedules and linen change. 7/23/24 resolution revealed,
DON had customer service in-service for all night shift staff & notified central supply staff member to keep
briefs available and on hand for resident.
In an interview on 7/31/2024 at 4:00 pm, the CNA revealed when a call light was on, she has responded
quickly to the resident. especially within the first 10 minutes. She stated not every CNA works like her; she
did not want to expound on that statement.
In an interview on 7/31/2024 at 6:15 pm with Resident #6, she stated she was the RCP and call lights were
still an issue even after she filed a grievance. She stated residents are waiting over 20 minutes for their call
lights to be answered throughout the day and evening.
In an interview on 7/31/2024 at 6:30 pm, R#5 revealed the call light took almost an hour to be answered.
In a telephone interview on 7/31/2024 at 7:20pm, RPOA-C revealed nursing services are horrible. Stated
her FM is always calling her about how it takes an hour or more for staff to answer their call lights.
In an interview on 7/31/2024 at 9:15 pm with the DON, she stated staff were in-serviced on answering calls
(she provided documentation of signed in-service). She states she has come to the facility in the early
hours to see if staff are doing their jobs. She states she knows this is an issue as residents have
continuously complained to her and as a result has been diligently doing the best she can to address. The
DON states her two ADON's also come into the facility unexpected during the morning hours (3rd Shift) to
see if resident's call lights are on. The DON showed text messages that she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676258
If continuation sheet
Page 3 of 10
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
has written to her night shift charge nurses telling them they are responsible for getting the call light issues
with the nursing staff under control. One of the text messages indicated staff would be disciplined if caught
not answering call lights or not doing their jobs.
Record Review of Facility's Policy on Resident Rights dated November 2021: Dignity and Respect Page 1
states You have the right to live in safe, decent and clean conditions; be treated with dignity, courtesy,
consideration and respect.
Event ID:
Facility ID:
676258
If continuation sheet
Page 4 of 10
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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
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** Based on
observation, interview, and record review, the facility failed to treat each resident with respect and dignity
and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 4
of 4 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for resident rights.
The facility failed to ensure staff assisted Resident #1, Resident #2, Resident#3 and Resident #4, by failing
to answer call lights in a timely manner to provide assistance.
This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase
anxiety.
The Findings include:
1. Record review of Resident#1's Face Sheet revealed an [AGE] year-old female admitted to the NF on
7/16/2024 with a diagnosis of hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm),
type 2 diabetes (body unable to produce insulin).
Record review of Resident#1's Baseline MDS assessment dated [DATE] did not reveal a BIMS score nor
was there an indication of resident's cognitive level.
Record Review of R#1's Care plan dated 7/16/2024 revealed resident was totally dependent on staff for all
her ADL's and staff was to ensure the call light is within reach.
On 7/31/2024 at 9:25 am, during an observation of Resident #1 revealed, she was lying in bed awake. She
appeared clean. Her face and hands were not dirty. Her hair was clean. Her call light was on her bed.
Observed the commode to be clean without any body fluids. During the attempted interview with Resident
#1 who was asked if she could answer a few questions, but she only stared and would not respond.
Resident #1's RPOA-A stated Resident #1 didn't feel like talking, but there were some concerns regarding
care and cleanliness. RPOA-A stated Resident #1 told him the room had not been cleaned at all on Sunday
and Monday. RPOA -A stated he came to the facility yesterday (7/30/2024) evening with a meal during
evening mealtime. He stated he personally observed the unclean RM and feces on the floor by Resident
#1's bed. RPOA-A stated they were not able to eat because to assist Resident #1 to sit up in bed to eat,
would have place him a position to step in the feces that was on the floor by her bed. RPOA -A stated the
Commode (bedside toilet seat), which was positioned approximately 3-4 feet from Resident #1's bed, had
not been emptied and was full of urine and feces. RPOA -A stated Resident #1 informed him when using
commode and wiping afterwards, Resident #1's hand would be dirty of the feces because of the toilet paper
filled to the top of the commode for her continuous usage and no one to clean. RPOA -A was informed by
Resident #1 that no one answered her call button for assistance, and she tried to get to the commode by
herself. However, she had an accident and used the bathroom on the floor. RPOA -A complained, and
housekeeping came and cleaned it up. Afterwards they were able to eat the evening meal he came with.
RPOA -A did not take any photos.
1. Record review of Resident #2's Face Sheet dated 7/26/2024 revealed a [AGE] year-old male with a
diagnosis of Rhabdomyolysis (breakdown of muscle tissue), acute kidney failure, hypothyroidism(thyroid
gland does not produce enough thyroid hormone).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676258
If continuation sheet
Page 5 of 10
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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
Record review of Resident #2's baseline MDS dated [DATE] did not reveal a BIMS score nor was there an
indication of resident's cognitive level.
Record Review of Resident #2's Care plan dated 7/24/2024 revealed Resident #2 had bowel incontinence.
Check resident every two hours and assist with toileting as needed; provide bedpan/bedside commode;
provide pericare (washing genitals and anal area) after each incontinent (no control over bowel movement
or urination) episode.
On 7/31/2024 at 9:40 am, during an observation , Resident #2 was lying in bed, covered and asleep. There
was an IV being administered and his call light on his bed. He appeared clean and shaven. There was no
attempted interview as Resident was sleeping. Resident #2's RPOA-B was standing next to the bed and
had some concerns regarding staffing and cleanliness.
In an interview on 7/31/2024 at 9:45 am with RPOA-B revealed some concerns regarding Resident #2's
care. RPOA-B stated a FM wrote an email to the HR Department of the facility voicing concerns for the lack
of urgency when the call light is pushed. She states it takes over 30 minutes for staff to answer the call
lights.
2. Record Review of Resident #3's undated Face sheet revealed a [AGE] year-old male admitted to the NF
on 7/10/2024 with a diagnosis to include type 2 Diabetes Mellitus (body doesn't produce enough insulin),
Hypertension (high blood pressure) and Poly-osteoarthritis (arthritis in five or more joints at the same time).
Record review of Resident #3's MDS dated [DATE] did not reveal a BIMS score nor was there an indication
of resident's cognitive level.
Record Review of Resident #3's Care plan dated 7/10/2024, revealed Resident #3 was at risk for falls r/t
weakness The interventions were staff are to be sure call light was within reach and encourage the resident
to use it for assistance as needed. The resident needs prompt response to all request for assistance.
In an Interview on 7/31/2024 at 9:50 am with Resident #3 regarding call lights he stated most times the call
button goes unanswered and when it is answered, the normal response time is over 30 minutes. Resident
#3 states a dissatisfaction with the nursing service.
3. Record review of Resident #4's Face Sheet revealed a [AGE] year-old male admitted to the facility
7/24/2024 with a diagnosis of Epilepsy (Seizures) and Todd's Paralysis (temporary paralysis after epilepsy),
hypertension (high blood pressure), schizoaffective disorder (hallucinations and delusions).
Record review of R#4's MDS dated [DATE] did not reveal a BIMS score nor was there an indication of
resident's cognitive level.
Record Review of Resident #4's Care plan dated 7/24/2024 reveals Resident #4 was at risk for elopement
(Leaving the facility without permission or proper discharge) and adverse drug reaction (unintended events
attributed to the use of medicines).
In an interview on 7/31/2024 at 10:00 am, Resident #4 stated the response time for a call button response
is about an hour. He states night shift does not respond at all.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676258
If continuation sheet
Page 6 of 10
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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
4. Record Review of Grievances listed below revealed concerns in achronological order:
Level of Harm - Minimal harm
or potential for actual harm
5/15/2024 Resident complained about not being immediately changed. Staff terminated.
Residents Affected - Few
5/29/2024 Resident alleged a CNA was rude to him when he told her he needed to use his urinal. Resident
was told he could just use his brief. CNA removed from the schedule permanently. Staff in-service on abuse
& neglect and customer service.
7/21/2024 Resident alleged call light is on for 1hr & a half and nebulizer was on window seal out of reach.
Resident state she couldn't get her nebulizer for over an hour. Facility went over resident medications.
Customer service for night shift staff and notified.
7/21/2024 Resident alleged during the 11p-7a shift call lights were on 2hrs. Stated staff changed briefs, but
resident told to wait for bed linen to be changed on 7a-3pm. 7/22/224 Facility staff listened to concerns,
discussed plan of care regarding briefs, shower schedules and linen change. 7/23/24 resolution revealed,
DON had customer service in-service for all night shift staff & notified central supply staff member to keep
briefs available and on hand for resident.
In an interview on 7/31/2024 at 4:00 pm, the CNA revealed when a call light was on, she has responded
quickly to the resident. especially within the first 10 minutes. She stated not every CNA works like her; she
did not want to expound on that statement.
In an interview on 7/31/2024 at 6:15 pm with Resident #6, she stated she was the RCP and call lights were
still an issue even after she filed a grievance. She stated residents are waiting over 20 minutes for their call
lights to be answered throughout the day and evening.
In an interview on 7/31/2024 at 6:30 pm, R#5 revealed the call light took almost an hour to be answered.
In a telephone interview on 7/31/2024 at 7:20pm, RPOA-C revealed nursing services are horrible. Stated
her FM is always calling her about how it takes an hour or more for staff to answer their call lights.
In an interview on 7/31/2024 at 9:15 pm with the DON, she stated staff were in-serviced on answering calls
(she provided documentation of signed in-service). She states she has come to the facility in the early
hours to see if staff are doing their jobs. She states she knows this is an issue as residents have
continuously complained to her and as a result has been diligently doing the best she can to address. The
DON states her two ADON's also come into the facility unexpected during the morning hours (3rd Shift) to
see if resident's call lights are on. The DON showed text messages that she has written to her night shift
charge nurses telling them they are responsible for getting the call light issues with the nursing staff under
control. One of the text messages indicated staff would be disciplined if caught not answering call lights or
not doing their jobs.
Record Review of Facility's Policy on Resident Rights dated November 2021: Dignity and Respect Page 1
states You have the right to live in safe, decent and clean conditions; be treated with dignity, courtesy,
consideration and respect.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676258
If continuation sheet
Page 7 of 10
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, and record review, the facility failed to maintain an effective pest control program so
that the facility was free of pests for two (hall 100 & 300) of three halls, in that:
Residents Affected - Few
The facility continues to have an infestation of roaches in residents' rooms, nursing stations, on medication
carts, hallways and reception area.
This failure placed residents, visitors, facility, and staff at risk of pest infestation, and a negative impact on
the physical environment and cleanliness of the facility.
The findings were:
Record Review of Pest Control Dates:
February 2, 2024-Treated all rooms in wing 300, cleaned and checked rodent bait stations and replaced
bait.
February 16, 2024-Treated every room in 300 and 400 hallway and therapy room in 200 hall for small
cockroach activity.
March 1, 2024 - Treated rooms in 300 and 400 hallways for small cockroach activity.
March 22, 2024-Inspected interior and checked all pest signting logs which had requests for 300 and 400
hallways. Treated gaps in baseboards in hallways.
April 5, 2024 - Checked all logbooks and pest sighting logs which had a request for room [ROOM
NUMBER]. Inspected room [ROOM NUMBER] and found activity in tv. Treated rooms again in 300 and 400
hallways. No activity found in 400. Only rooms with activity are in 300 hallway and are found in clutter in
closets.
April 19, 2024-Inspected common crawling pests and roaches primarily. No signs of roaches alive or
captured.
May 3, 2024 -Courtesy visit to assist cleanburn at account and training
May 22, 2024-treated commong areas, entry points, snack bars, kitchen area, laundry rooms, behind
kitchen, back laundry warehouse and cleaning closets. Targeted large and small cockroaches
June 21, 2024- treated interior entry ways and common areas. Cockroaches reported in dining room, spot
treated corners of dining room and a couple wall openings were dusted. Spot treated cracks and crevices of
kitchen area. Treated and set monitors out in pantry/dry storage.
July 12, 2024 - serviced the bait stations along the back side before the rain kicked up. Spot treated some
active wasp nests while inspecting. Two employees reported small roaches. 1. Very minor German roach
activity in desk of the receptionist. 2. Moderate to heavy German roach activity observed in the activities
room. Baited heavily and installed insect monitors.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676258
If continuation sheet
Page 8 of 10
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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 0925
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
July 24, 2024 - Treated rooms 104,106,200,201,203,205-218,315,402,403. Treated drains on the different
wings, piney point bistro, creek café, [NAME] hill lounge and spring bistro, treated back of kitchen
and dishwashing area, front reception desk, treated main dining area. Maintenance did not report any roach
activity.
July 25, 2024 - In recreation center - small roach activity in the reception desk on the side facing the front
door and wing four room [ROOM NUMBER]. Mainly in the mini fridge, base covers, trash can, restroom.
Only around 20 live roaches running around. Majority were in an electric hole punch. We tossed the device
out as it is infested with roaches. Dusted cracks and crevices and baited individual roaches. Captured 2
juvenile roaches at reception.
Record Review of the [Active Pest Log] dated 1/16/2024 - 7/20/2024:
January 16, 2024, roaches on nurses' station:
January 17, 2024, roaches in room [ROOM NUMBER]
January 17, 2024, roaches in room [ROOM NUMBER]
January 18, 2024, roach infestation in room [ROOM NUMBER]
February 6, 2024, Roaches in rooms 320; 326, 302B, 327, 304 and the nurse's station
February 11, 2024 roaches in rooms 314 & 317
March 8, 2024, roaches seen in room by occupant
April 2, 2024, Roaches seen in room [ROOM NUMBER]
April 10, 2024, Roaches in med room & nurses station
April 19 2024, Roaches in the med room and hallway
July 29, 2024, med room bunch of dead roaches
July 30, 2024, roaches in room [ROOM NUMBER]
Observation on 7/31/24 at 9:50 pm, revealed a small roach was observed running across the notepad that
was on the conference room table.
In an interview on 7/31/2024 at 9:40 am, Resident #4 stated he saw a roach climb up the walls recently and
had brought that to the attention of an unknown charge nurse a few days ago.
In an interview on 7/31/24 at 2:39 pm with MS who stated he was unaware of the facility's policy that
indicated pest control will be monthly. He stated he was responsible for ensuring Pest Control is called and
come to the facility. He stated he is the contact person for the Pest Control company. He stated there has
been a roach infestation problem in the facility for over a year. He stated residents have reported this
problem to nursing staff who placed the information in the Versacor Log (maintenance sighting log used to
identify any issues in the facility regarding roaches or bugs anywhere
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676258
If continuation sheet
Page 9 of 10
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
676258
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial City Nursing and Rehabilitation Center
1341 Blalock
Houston, TX 77055
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 0925
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
in the facility for the maintenance supervisor to review). He stated staff are to report roaches as they see
them, then he will call Pest Control to come out. He initially stated he had not seen any roaches since pest
control last month. He then stated he seen a roach run in the 400 hallway on or about July 15, 2024, or July
16, 2024. He stated he killed it by stepping on it, then cleaned the area where he stepped on it. Afterwards,
MS stated he called and was told the hurricane had thrown the schedule off and was told they would be out
on July 24, 2024. He could not offer any reason why no pest control was administered in January 2024. He
could not offer a reason why there was only one application in June 2024.
In an interview on 7/31/24 at 3:49 pm, AA stated, she saw multiple roaches that past Sunday Morning,
7/28/24 in the activities room when she turned the lights on. The roaches scattered, but she didn't stay in
there long enough to investigate where they scattered to. She stated informed her supervisor without
making any notation in the folder located at the nurse's station. She said she was informed by her
supervisor that the pest control guy would be coming out soon.
In an interview on 7/31/2024 at 8:45 pm, the LVN stated, there were a lot of roaches throughout the facility.
She stated she typically stand or sit on a stool while working. She states when passing medications, she
will not lean on the med cart because she has seen roaches on the medication cart.
In an interview on 7/31/24 at 9:15 pm, the DON stated she was aware of continued issues regarding
roaches. She said Pest Control has been coming twice per month to address and spray for the roach issues
throughout the facility. When informed the roach problem is concerning because it's been more than a year
and the roach issue still exist, the DON stated she will call the pest control company to see if there is
anything else they can do. She stated another option she will use is get another pest control company.
Record Review of the facility's Pest Control Policy dated 4/1/2017 revealed, every month service specialists
will service each area throughout the facility. However, should the need arise, calls from the facility
requesting assistance to a pest issue will be responded to within 30 minutes of the call being received, and
an on-site visit will be conducted within 24 hours.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676258
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FAQ · About this visit
Common questions about this visit
What happened during the July 31, 2024 survey of MEMORIAL CITY NURSING AND REHABILITATION CENTER?
This was a inspection survey of MEMORIAL CITY NURSING AND REHABILITATION CENTER on July 31, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MEMORIAL CITY NURSING AND REHABILITATION CENTER on July 31, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
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.