Inspection·September 24, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN A documented Resident #1's change of condition, physician notification, and transport to hospital on [DATE]. This failure could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #1's face sheet dated 09/20/24 indicated he was a [AGE] year old male, admitted on [DATE] and his diagnoses included acute respiratory failure with hypoxia (impaired gas exchange between lungs and blood resulting in low oxygen levels in body tissues). Record review of Resident #1 physician orders dated 8/29/24 indicated Resident #1 was on enteral feed (feeding through G-tube) and he was administered medications via G-tube (feeding tube) for SOB, infection, dementia (gradual decline in cognitive abilities that interferes with daily life), and HTN (high blood pressure). Record review of Resident #1's discharge MDS dated [DATE] indicated Resident #1 was discharged with return anticipated. Record review of Resident #1's care plan dated 08/30/24 the facility would provide Resident #1 and his representative a summary of the base line care plan within 48 hours. Resident #1 had the following special treatments/needs: for treatment included IV medications, hospice care, tracheostomy (opening in the neck into the windpipe/trachea to allow air to flow into the lungs), suction, oxygen, CPAP (a machine that sues mild air pressure to keep breathing airways open while sleeping), isolation, wound vac (a treatment that uses a suction pump and dressing to help heal wounds), dialysis, diabetic care, and pressure ulcers. Record review of a progress note dated 08/30/24 at 8:39 a.m., completed by LVN A indicated Resident #1 was hospitalized . There was no documentation of Resident #1's change of condition, vital signs, physician notification, treatment or care provided, or that he was transported to hospital for evaluation and treatment. Record review of Resident #1's hospital records dated 08/30/24 indicated Resident #1 admitting (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: 676484 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 676484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523 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)