Inspection·July 1, 2025

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** During observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for the 300 and 400 halls, in that: The facility continues had an infestation of roaches in Residents' rooms as observed in the following: 317,321,323, 327 and 405. This failure could expose Residents to infection and decreased quality of life. During observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for the 300 and 400 halls, in that: The facility continues had an infestation of roaches in Residents' rooms as observed in the following: 317,321,323, 327 and 405. This failure could expose Residents to infection and decreased quality of life. Facility's record review shows, Resident # 4 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was admitted with the following diagnoses: Cerebral infarction unspecified, Type 2 diabetes, Morbid obesity, Hyperlipidemia, Recurrent depression, Hypertension, Aphasia, Hemiplegia and Hemiparesis related to cerebral infarction affecting the left dominant side, Abnormality of gait and mobility, Lack of coordination, Retention of urine, Cognitive communication deficit, Dysarthria and anarthria, Obstructive and reflux uropathy. Facility's record review show, Resident #1 was a [AGE] year old male, admitted to the facility on [DATE], with the following comorbid factors: Muscle wasting and atrophy, Atrial flutter, Gait and mobility abnormalities, Cognitive communication deficit, Hypertension, Protein malnutrition, Chronic kidney disease, Non-pressure chronic ulcer of the right lower leg, Atherosclerotic heart disease, Ulcer of the right foot, Hyperlipidemia, Unspecified dementia without behavior, Presence of cardiac pacemaker, Chronic Obstructive pulmonary disease and Pulmonary edema. Facility's record review shows Resident # 2 was a [AGE] year-old male, admitted on [DATE] with the following diagnoses: Alcoholic cirrhosis f the liver with ascites, Diabetes mellitus, Recurrent depressive disorder, Benign prostatic hyperplasia, and Transient ischemic attack Observation, and interview with Resident # 2 on 07/01/2025 at 08:10 am in his room, he stated there are always roaches running around in his restroom. He has a BIM's score of 14. Resident # 2 said, come with me, and I will show you where most of the roaches are. Investigator and Resident # 2 saw two roaches crawling on the restroom floor. Resident #2 stated, they come out like this all the time. Both at night and during the day. The roaches disappeared into the cracks on the floor. Resident stated: They don't clean good around here. In an interview with Resident # 4's family on 06/30/2025 at 11:00 am at his bedside at the hospital, she said she and her family saw roaches at different instances when their dad, Resident # 4 was at the facility prior to hospitalization. She vividly remembered two dates: On 06/01/2025, my family member killed a roach. On 06/02/2025 my other family member killed another roach. I cannot remember the other dates. In an interview on 06/30/2025 at 3:20 pm with Resident # 1 in his room, he pointed to a hole where he said, the roaches come out and goes back in all the time. He sees them from his bed. Yes, I see roaches. I saw one yesterday running around the toilet bowl. I did not tell anyone. Residents Affected - Some (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: 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 07/01/2025 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)