Inspection visit

Health inspectionAugust 15, 2024

CONTINUING CARE AT EAGLES TRACECMS #6763365 citations on this visit

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensured that residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary trat infections and restore continence to the extent possible in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 (Resident #13) residents reviewed for quality of care. The NF failed to secure Resident #13 suprapubic catheter tubing to prevent from dislodging. This failure could place residents at risk for injury, hospitalization, and decrease in quality of life. Findings include: Record review of Resident #13's face sheet, dated 08/15/2024, reflected a 90- year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included the following: hemiplegia (paralysis on one side of the body), dysarthria (slow or slurred speech) following a cerebral infarct (when blood flow to the brain is blocked), and benign (tumor, or growth that is not cancerous) and prostatic hyperplasia (enlarge prostate gland that can cause difficulty in urinating). Record review of Resident #13's annual MDS, dated [DATE] , reflected that the resident had a BIMS score of 2, indicating which indicated resident cognition was severely impaired. Section H (bladder and bowel) was coded 9 (not rated, resident had a catheter [(indwelling, condom]), urinary ostomy, or no urine output for entire the 7 days. Record review of Resident #13's care plan, dated 08/13/2024, revealed reflected the that resident was being care planned for having a 16 fr suprapubic catheter (surgically placed tube into the bladder through a small incision in the lower abdomen [(stomach]) with intervention to manage protective garment and/or continence products to empty catheter bag to measure urinary output. Record review of Resident #13's physician orders for the month of August 2024 revealed reflected the following order: -Indwelling urinary Foley, change suprapubic Foley q month, dated 07/15/2024. Observation on 08/15/2024 at 9:07 AM of Resident #13 revealed the resident in bed with a suprapubic catheter draining cloudy yellow urine. The resident tubing was not secured to prevent pulling on (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 8 Event ID: 676336 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 676336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Care at Eagles Trace 14703 Eagle Vista Drive Bldg 601b Houston, TX 77077 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 0690 the tubing. The site at the suprapubic catheter was clean without drainage or redness. Level of Harm - Minimal harm or potential for actual harm Interview on 08/15/2024 at 9:10 AM, CNA B said he had been working at the NF for 5 years and 3 months. CNA B said he received an in-service on making sure Foley catheters were draining well, keeping the site clean and dry, and securing the tubing by using a statlock (catheter stabilization device) to prevent pulling. CNA B said he believed it was the nurses who placed the statlock on resident's that had an indwelling Foley catheter. CNA B said he was not aware Resident #13 did not have a statlock to secure the tubing from pulling. Residents Affected - Few Interview on 08/15/2024 at 9:18 AM, RN A said she was the nurse for Resident #13. RN A said it was the NF policy any resident who had an indwelling Foley catheter to place a statlock on the tubing to prevent pulling on the tubing, injuring the resident, and dislodging the tube. RN A said it was the nurse's responsibility to ensure that a statlock was placed on the resident (s) who had indwelling Foley catheters. RN A said it was the CNA's responsibility to report to the nurse if the statlock came off the resident . Interview on 08/15/2024 at 2:04 PM, the DON said the nursing staff should be securing the tubing for any resident who had a Foley catheter to prevent injury to the resident. Record review of the facility's policy on Urinary Catheters, dated 07/2021, reflected in part: .Secure suprapubic catheter to the abdomen to prevent accidental dislodgement or removal-allow room and do not pull catheter taut (tight) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676336 If continuation sheet Page 2 of 8 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 676336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Care at Eagles Trace 14703 Eagle Vista Drive Bldg 601b Houston, TX 77077 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 used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for standards in 1 of 1 medication (Resident #83) rooms reviewed for medication storage. -The facility failed to discard Resident #83 medication IV antibiotic cefepime that expired on 08/14/2024. This failure could place residents at risk for not receiving adequate antibiotic therapy to treat infection. Findings include: Record review of Resident #83's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83 had diagnoses which included cellulitis (bacterial skin infection) of right lower limb (arm or leg) and lymphedema (swelling that that occurs in an arm or leg). Record review of Resident #83's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83 had diagnoses which included cellulitis (bacterial skin infection) of right lower limb (arm or leg) and lymphedema (swelling that that occurs in an arm or leg). Record review of Resident #83 admission MDS, dated [DATE], reflected the resident had a BIMS score of 15, which indicated the resident's cognition was intact. The resident received antibiotic therapy. Record review of Resident #83's care plan, dated 08/06/2024, reflected the resident was being care planned for receiving cefepime 1 gram intravenous every 8 hours for 21 days (till 08/22/2024) for cellulitis. Record review of Resident #83's Physician orders reflected the following order: Cefepime 1 gram solution for intravenous for cellulitis every 8 hours for 21 days, dated 08/02/2024. Record review of Resident #83's MAR for the month of August 2024 reflected the resident was receiving the medication cefepime every 8 hours at 6AM, 2PM, and 10PM. Observation on 08/15/2024 at 8:45 AM revealed the medication room fridge had two 50ml bags of normal saline mixed with cefepime 1gm for Resident #83. The expiration date on the bags read 08/14/2024. Interview on 08/15/2024 at 8:46AM, the ADON said all the nurses should be checking for expired medications prior to placing in the fridge and before administering the medication. Interview on 08/15/2024 at 2:04 PM, the DON said she would have to looked at the expired medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676336 If continuation sheet Page 3 of 8 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 676336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Care at Eagles Trace 14703 Eagle Vista Drive Bldg 601b Houston, TX 77077 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 cefepime for Resident #83 to see what may have happened. The DON said audits were done in the medication room by herself, the ADON, and pharmacy for expired medications. Record review of the facility's policy on Medication Administration, Receipt, Storage & Disposal, dated 10/2023, reflected in part: Residents Affected - Few .Medication management in Continuing Care will include ordering, transcribing, receiving, proper storage, accurate documentation and safe administration of residents' medications by authorized staff, consistent with state requirements . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676336 If continuation sheet Page 4 of 8 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 676336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Care at Eagles Trace 14703 Eagle Vista Drive Bldg 601b Houston, TX 77077 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/preparation discarded after 72 hours. 3. The facility failed to keep food off the floor. 4. The facility failed to keep scoops in a separate holder from bulk food bin. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility's kitchen on 08/13/24 at 8:15 AM revealed the following. 1. A plastic container of Blue Cheese had No Label and No use by Date. 2. A Plastic container of sliced Swiss Cheese in the walk-in cooler had a used by date of 8/10/24. 3. A cs of fresh sliced mushroom in the walk-in cooler had a use by date of 8/09/24 4. 2cs. Of wheat bread in the walk-in freezer were stored on the floor. 5. 1cs. Of breaded chicken in the walk-in freezer was stored on the floor 6. 4 cs. Of ice cream individual cups in the walk-in freezer were stored on the floor. 7. 2 cs. Sausage in the walk-in freezer were stored on the floor. 8. Scoops were left in cornbread, flour, and sugar bins In an interview with the General Manager of Dining on 08/13/24 at 8:30 AM; she stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date. She stated the Cases of food should be off the floor and the scoops were stored. She said she would be re-in-service dietary staff on labeling & dating. She said the tray aides are responsible for checking the food in the walk in and to discard food prior to the used by date. Record review of facility's policies and procedures for Food Safety, dated 05/2012 read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 72 hours unless otherwise indicated. Record review of facility's policies and procedures for Food Storage, dated 04/2016 read in part '' .All food and supplies will be stored six (6) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676336 If continuation sheet Page 5 of 8 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 676336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Care at Eagles Trace 14703 Eagle Vista Drive Bldg 601b Houston, TX 77077 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 0812 Inches above floor. 6.Scoops for dispensing dry bulk foods these items will be stored separately in a holder. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676336 If continuation sheet Page 6 of 8 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 676336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Care at Eagles Trace 14703 Eagle Vista Drive Bldg 601b Houston, TX 77077 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 observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters dumpster A and dumpster B reviewed for Residents Affected - Some Food and nutrition services. -The facility failed to ensure all garbage was dispose properly in the dumpster and not left outside of dumpster. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 08-13-24 at 8:45 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and a bag full of garbage was left on top of the dumpster lid. In an interview on 08-13-24 at 8:45 am, with the General Manager of Dining Services, she stated the bag full of garbage should have been put in the dumpster and not left on top of the dumpster. She also stated the dumpster doors must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She further stated housekeeping, and nursing also discarded their waste garbage in the dumpster. It was the responsibility of dietary staff, nursing and housekeeping to ensure the dumpster doors were kept closed and all garbage should be put in the dumpster. Record review of facility's Policies and Procedures on waste disposal, dated 6/ 2023, reflected trash containers liners are secured, collected, and deposited in the designated dumpster. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676336 If continuation sheet Page 7 of 8 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 676336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Care at Eagles Trace 14703 Eagle Vista Drive Bldg 601b Houston, TX 77077 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 storage rooms (Room A and Room B) reviewed for infection control. Residents Affected - Few -The facility failed to keep infection control gowns and pillows off the floor in the storage rooms. This failure could place residents at risk of cross-contamination and development of infection. Finding include: Observation of the laundry room and linen closets on 08/15/2024 at 2:00 PM revealed 2 yellow gowns on the floor of Room A and 3 blue plastic resident pillows on the floor of Room B. Interview with the Facility Manager and the Director of HK on 08/15/2024 at 2:02 PM, they said they did not know if it should be on the floor. They did not know why the items were on the floor. Interview with the Administrator and DON on 08/15/2024 at 2:40 PM, the Administrator said the items might have fallen from the shelves. The DON said the pillows and gowns should not have been on the floor as everything should be elevated off the floor due to infection control. Record review of the facility's Housekeeping, Maintenance and Laundry Services Policy, dated May 2021, reflected the facility will provide sufficient housekeeping, maintenance, and laundry personnel to maintain interior and exterior of the facility in a safe, clean, orderly and attractive manner. Interior walls and floors will be of a character to permit frequent and easy cleaning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676336 If continuation sheet Page 8 of 8

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Citations

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.

0761GeneralS&S Dpotential for harm
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.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0814GeneralS&S Epotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2024 survey of CONTINUING CARE AT EAGLES TRACE?

This was a inspection survey of CONTINUING CARE AT EAGLES TRACE on August 15, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CONTINUING CARE AT EAGLES TRACE on August 15, 2024?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."

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 June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·August 15, 2024