Inspection visit

InspectionJune 12, 2024

Sylan Shores Health and WellnessCMS #6764905 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 18 residents (Resident #66) reviewed for their right to voice grievances to the facility. The facility failed to report and document Resident #66's complaint about her hearing aids that stopped working after a shower. This failure could place residents at risk for harm by not having their grievances addressed. The findings included: Record review of Resident #66's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, but were not limited to, Essential hypertension (high blood pressure), type 2 diabetes mellitus without complications (a problem in the way the body regulates and uses sugar as a fuel), chronic kidney disease, cardiac pacemaker, heart disease and muscle wasting and other lack of coordination, Record review of Resident #66's admission MDS dated [DATE] indicated she was not assessed on her mental capacity, her BIMS score was left blank. Record review of section B of her MDS, Hearing, speech, and vision, she was assessed as 2 moderate difficulties in hearing, hearing aids was checked yesindicated she had hearing aid. On speech, she was assessed as having clear speech, distinct intelligent words. Ability to express ideas and wants, (consider both verbal and non-verbal expression) she was assessed as understood. Ability to understand others was assessed as understood. Record review of Resident #66's care plan dated 03/30/24 with a target date of 06/28/24 read in part, Resident had a communication problem r/t Hearing deficit. Goals: The resident will be able to make basic need known daily. Interventions: Allow adequate time to respond, Repeat as necessary. Allow adequate time to respond, Repeat as necessary . Use simple, brief, consistent words/cues, alternative communication tools as needed. During observation and interview on 06/10/24 at 10:15 AM, Resident # 66 was observed in her room on her I-pad. In an interview, she said I cannot hear. Speak louder, speak louder. Resident was (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 7 Event ID: 676490 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0585 allowed to continue with her program after a brief conversation. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 06/11/24 at 1:20 PM, Resident was observed on the phone with a family member. She kept saying to speak louder. In an interview with Resident #66 she said, It was very frustrating trying to communicate and cannot hear what is being said. She said she had hearing aids but one of the CNAs gave her a shower without removing them and they got wet and had not worked since. She said she told one of the nurse's but does not remember her name. She did not remember the date but said it was before she went to the hospital about two weeks ago. She said she also told her responsible party. Residents Affected - Few During an interview with the DON on 06/11/24 at 2:00 PM, she said she was not aware that Resident #66 had hearing aids. LVN Z (who was standing by) said Resident #66 has hearing aids, but they don't work because she said they got wet in the shower. LVN Z said the hearing aids were in her drawer. In an interview with the facility Administrator on 06/11/24 at 3:00 PM, she said she would find out how long ago and who gave her a shower with her hearing aids on. She said she would investigate. She said Resident #66 did not remember the exact date and she could not find out the staff that gave her shower. Attempt was made to contact Resident #66's responsible party on 06/12/24 at 3:40pm and but did not answer. Message was left. During an interview on 06/12/24 at 8:40Am, the Administrator said Resident #66 did not remember when and how long ago. She said the facility could not find out who gave Resident #66 a shower. She said Resident's responsible party was contacted and he would find the receipt for the hearing aids to take them to the same place. She said if not, the facility would arrange for audiologist clinic that would see her. During an interview with LVN Z on 06/12/24 at 9:30AM, she said she forgot about it until yesterday when she heard surveyor asked about it. She said she was supposed to document and notify the DON and the Administrator. She said she did not remember the exact date. Record review of the facility's policy undated titled Excerpt - Operations Manual Grievances read in part, The investigation of complaints and grievances is a vital function to protect the health, safety, and welfare of residents. The administrator is designated as the Grievance Official and is responsible for ensuring that all complaints and grievances are investigated and resolved in a timely and appropriate manner. This responsibility includes: overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the community; and maintaining the confidentiality of all information associated with grievances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 2 of 7 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #6, #61 and #66) of 24 residents reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Resident #6 was coded in the MDS for a fall. The facility failed to ensure Resident #61 was coded correctly in the MDS for a fall. The facility failed to accurately assess Resident #66 for her cognitive patterns (mental capacity) on her admission MDS assessment. These failures could place residents at risk of not having all medical needs assessed and met. Findings Included: Resident #6 Record review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included, but were not limited to, Multiple Sclerosis, muscular dystrophies (diseases that cause progressive weakness and loss of muscle mass) urinary tract infection, intellectual disability, anxiety abnormalities of gait and mobility. Record review of Resident #6's admission MDS dated completed on 05/03/2024 revealed a BIMS score of 7 which indicated severe impaired cognition. Review of section J fall history any fall since admission\entry or reentry, or prior assessment was checked 0 was indicated no falls. Record review of Resident # 6's care plan dated 08/22/2022 with a target date of 08/01/2024 revealed she was care planned for falls. Record review of facility's accident and incidents log dated 12/10/23 to 06/10/24 revealed Resident #6 had falls on the following dates 02/03/24, 04/17/24, 04/28/24, and 05/01/24. Observation on 06/10/24 at 11:00AM revealed Resident #6 was in bed alert and oriented to her name. Her family member was by her bed side. Attempt was made to have an interview, but she could not give any detailed history. Resident # 6's responsible party said, her disease had gotten worse, and she was on hospice. Resident # 61 Record review of Resident #61's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, Repeated falls, dementia, essential hypertension( high blood pressure) , type 2 diabetes mellitus without complications (a problem in the way the body regulates and uses sugar as a fuel) thyroid disorder (a medical condition that affects the function of the thyroid gland), depression, muscle wasting and other lack of coordination, cognitive communication deficit ( difficulty in communicating) and urinary tract infection. Record review of Resident #61's Quarterly MDS assessment completed on 05/15/2024 revealed a BIMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 3 of 7 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few score of 11 which indicated moderate impaired cognition. Review of section J fall history any fall since admission\entry or reentry, or prior assessment was checked 0 was indicated no falls. Record review of Resident #61's Quarterly MDS completed on 04/12/24 revealed a BIMS score of 11 which indicated moderate impaired cognition. Review of section J fall history any fall since admission\entry or reentry, or prior assessment was checked yes numbers of fall was marked as 1 indicating she had one fall since admission, entry-reentry and last assessment. Record review of facility's accident and incidents log dated 12/10/24 to 05/10/24 revealed Resident #61 had falls on the following dates 02/04/24, 03/14/24, and 05/13/24. Record review of nurse's documentation read in part, 3/14/2024 04:57 Nurse's Note: Resident found on the floor in her room in the doorway of the bathroom. Resident clothes were wet, and she wasn't wearing any footwear. Resident denies any pain, no visible injuries observed. Vitals T 97.1, BP 175/84, P 62, R 20. Assisted back to bed and incontinence care provided. Resident encouraged to use call light for assistance with ambulation and toileting. Fall history 3/14/24. Observation and interview on 06/10/24 at 9:40 am revealed Resident #61 was in activities. She was alert and oriented. In an interview she said she had multiple falls but does not remember time and dates. Resident #66 Record review of Resident #66's electronic face sheet revealed [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, Essential hypertension (high blood pressure), type 2 diabetes mellitus without complications (a problem in the way the body regulates and uses sugar as a fuel), chronic kidney disease, cardiac pacemaker, heart disease and muscle wasting and other lack of coordination, Record review of Resident #66's admission MDS dated [DATE] revealed section C- Brief Interview for mental status section 200-500 was assessed as(-) indicated she was not able to answer questions. Section 600-100 staff assessment for mental status was also marked with dash - (unable to answer). Record review of section B of her MDS Hearing, speech, and vision, she was assessed as 2 moderate difficulties on hearing, hearing aid was checked yes- indicated she had hearing aids. On speech, she was assessed as having clear speech distinct intelligent words. Ability to express ideas and wants, (consider both verbal and non-verbal expression) she was assessed as understood. Ability to understand others (understanding verbal content, however able) was checked as understands. During observation and interview on 06/10/24 at 10:15AM, Resident # 66 was observed in her room on her I-pad. In an interview, she said was listening to her brotherhood conference and proceeded to explain that she listens to the pod cast daily to know what was going on around the world. When surveyor asked questions, she would say I cannot hear speak louder speak louder. Resident was allowed to continue with her program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 4 of 7 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with LVN K on 06/11/24 at 2:00PM, she said Resident #66 hears and speaks well. She said Resident #66 was hard of hearing, but she can understand and able to communicate. During an interview on 06/12/24 at 12:00 PM, MDS coordinator A said she was responsible for completing and ensuring that all MDS accurately reflected resident's condition. She said all MDS were updated quarterly and upon significant change. She said inaccurate assessment may result in not providing needed services. She said she would correct all identified MDS and resubmit them. She said section J of the MDS for Resident #6 and 61 were oversight and she would do an amendment and re-submit all identified MDS. She said the coding for Resident #66 was an error. Facility's policy on MDS accuracy was requested on 06/12/24 at 3:30PM from the Administrator and the MDS Coordinator. Both said the facility followed the RAI manual. Record review of CMS RAI manual dated 2017, version 1 of 15 read in part, The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 5 of 7 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 2 errors out of 25 opportunities which resulted in an 8% error rate involving 1 of 4 residents (Resident #89) and 1 of 3 employees (MA A) observed during medication administration reviewed for medication error, in that: Residents Affected - Few -MA A gave Resident #89 an incorrect dose of her Famotidine and antacid and antihistamine medication. -MA A gave Resident #89 an incorrect dose of her Tylenol a pain relieving and fever reducing medication. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings were: Resident #89 Record review of Resident #89's admission Record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following diagnoses: allergic rhinitis (an allergic response causing itching, watery eyes, sneezing, and runny nose), gastro-esophageal reflux disease (GERD), (condition that occurs when stomach contents like acid and partially digested food, flow back up into the esophagus), hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) and cerebral infarction due to thrombosis of left middle cerebral artery (a type of stroke that occurs when a blood clot or thrombus, blocks blood flow to the brain). Record review of Resident #89's physician order summary report dated active as of 6/12/2024 had the following medication orders: Famotidine Tablet 20 MG give 1 tablet by mouth one time a day for GERD and had an order date 12/20/2022 and start date 12/31/2022. There was no end date. Tylenol Oral Tablet 325 MG (Acetaminophen) Give by mouth two times a day for left shoulder give 325 mg 2 tab (sic)=650mg and had an order date 05/08/2024 and start date 05/08/2024. There was no end date. Observation and interview of Resident #89's medication administration pass performed by MA A on 6/11/24 at 9:42 am. MA A explained to Resident #89 that she was going to give her morning medication. MA A prepared Resident #89's medications after assessing the residents' vital signs. MA A placed one tablet of Famotidine 10 mg in Resident #89's medicine cup. MA A placed one tablet of Tylenol 325 mg in Resident #89's medicine cup. MA A gave Resident #89 the medicine cup with the tablets inside and Resident #89 swallowed all the tablets at one time with approximately 6-8oz of water. Record review of Resident #89's MAR dated 6/1/2024-6/30/2024 revealed MA A documented her initials and a check mark, indicated she had administered Famotidine Tablet 20 MG Give 1 tablet by mouth one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 6 of 7 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few time a day for GERD at 09:00am. Continued review of the MAR revealed MA A documented her initials and a check mark, indicating she had administered Tylenol Oral Tablet 325 MG (Acetaminophen) Give 325 mg by mouth two times a day for left shoulder pain give 325 mg 2 tab (sic)=650 mg at 6a-10am. Interview with MA A on 6/11/24 at 9:52 am and asked MA A to review the order of Famotidine for Resident #89. MA A looked at the box and looked at the order on her computer screen and MA A stated, Oh. I could have just given her 2 tablets to equal the 20 mg as ordered instead. MA A stated, I only gave 10 mg, and it should have been 20mg. MA A did not mention an error with the dose of Tylenol during the medication administration. Interview with the DON on 6/12/24 at 3:00pm she said she had only been the DON for about 3-4 weeks and had some work to do with training and retraining staff on a variety of things related to resident care and facility policies and procedures. The DON said that the medication aides and nurses should ensure the residents get the correct medications as ordered by their physicians. The DON said she would expect the residents to receive the correct medications and dosages. Record review of a facility provided policy and procedure titled Administering Medication and dated revised April 2019, read in part: 4. Medications are administered in accordance with prescribers' orders .10. The individual administering medication checks the label THREE (3) times to verify the right resident, right medication, right dosage .before giving the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 7 of 7

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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.

0585GeneralS&S Dpotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.

FAQ · About this visit

Common questions about this visit

What happened during the June 12, 2024 survey of Sylan Shores Health and Wellness?

This was a inspection survey of Sylan Shores Health and Wellness on June 12, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Sylan Shores Health and Wellness on June 12, 2024?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grie..."

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.

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·June 12, 2024