FFIII Houston SNF Tenant LLC

In the surveyor’s words

From the most serious findings on record at FFIII Houston SNF Tenant LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Mar 29, 2025

  Based on observations, interviews, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for one (Resident #1) of seven residents reviewed for change in condition. The facility failed to notify the NP immediately by phone call when Resident #1 was found on the floor holding his head and appeared confused after an unwitnessed fall. […]

• Immediate jeopardy, isolatedF684Mar 29, 2025

  Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to follow up with the on-call physician after not receiving a response which delayed Resident #1's transport to the ER after an unwitnessed fall which resulted in a subarachnoid hemorrhage and 6 hour delay in care. Resident #1 was sent to the hospital and admitted to the ICU. An IJ was identified on 3/27/2025. The IJ template was provided to the facility on [DATE] at 2:32 p.m. […]

• No harm, potential for more than minimal, patternF759Aug 28, 2025

  Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 14%, based on 5 errors out of 34 opportunities, which involved 3 of 6 residents (Residents #47, #167 and #76) and 3 of 3 staff observed during medication administration reviewed for medication errors. 1. The facility failed to administer Resident #76's antibiotic, Bactrim (Sulfamethoxzole-trimethopine tablet) and Centrum Silver Gel as ordered by the physician on 8/27/25. 2. The facility failed to administer Resident #167's Pantoprazole before breakfast per the pharmacy label instructions on 8/27/25. 3. […]

• No harm, potential for more than minimal, patternF761Aug 28, 2025

  Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and, in accordance with State and Federal laws, drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three of four medication carts (Nurse Cart 1B [middle Hall], Nurse Cart 2A Hall, Nurse cart 2B [middle Hall]) reviewed for storage of medications . […]

• No harm, potential for more than minimal, patternF880Aug 28, 2025

  Based on observation, interview and record review the facility failed to establish and 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 3 of 3 residents (Resident #119, Resident #182 and Resident #153) reviewed for infection control. 1.The facility failed to ensure C.NA A and LVN E used the required PPE for Resident #119, who was on enhanced barrier precautions while assisting with repositioning in bed, LVN E picked up blanket from the floor and placed on 8/26/25. 2. The facility failed to ensure LVN E used the required PPE for Resident #153 on 8/28/25. 3. […]