Mason Creek Transitional Care of Katy

In the surveyor’s words

From the most serious findings on record at Mason Creek Transitional Care of Katy, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Nov 7, 2024

  Based on observation, interview, and interview, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 9 residents (CR #1) reviewed for change of condition. The facility failed to notify CR #1's physician or seek medical guidance when he experienced a drop in oxygen saturation during physical therapy just after breakfast on [DATE]. At approximately 3:00 p.m., CR #1 experienced a drastic desaturation (a decrease in oxygen saturation, low blood oxygen concentration) to 53% after a shower and resulted in loss of consciousness, initiation of CPR, and intubation (a medical procedure that involves inserting a flexible tube into the trachea to help maintain an open airway). […]

• Immediate jeopardy, isolatedF695Nov 7, 2024

  Based on observation, interview, and interview, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the resident's goals and preferences for 1 of 9 residents (CR #1) reviewed for respiratory care. 1. The facility failed to increase CR #1's oxygen or consult/seek further guidance from CR #1's physician to increase his oxygen to ,d+[DATE] L/min during a shower on [DATE] after his family members informed staff his oxygen requirement increased during exerting activities, including showers. […]

• Immediate jeopardy, isolatedF600Sep 25, 2024

  Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #1) reviewed for resident abuse. The facility failed to prevent Resident #1 from being physically abused by LVN B on 12/05/23. The noncompliance was identified as past noncompliance (PNC) IJ. The noncompliance began on 12/05/23 and ended on 12/12/23. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. Findings included: Record review of Resident #1's face sheet dated 09/25/24 revealed an [AGE] year-old female admitted to the facility initially on 11/09/21 and readmitted [DATE]. […]

• No harm, potential for more than minimal, patternF686Aug 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the facility ensured a resident with pressure ulcer received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 (Resident #3) of 4 residents and 10 out of 41 days reviewed for quality of care, WCN A, LVN D, and LVN E did not provide wound care for Resident #1 for his buttocks and foot areas for the following dates: 7/6/25, 7/13/26, 7/18/26, 7/19/26, 7/21/26, 7/22/26, 7/24/26, 7/25/26, 7/27/26 and 8/3/2026.This failure could place residents at risk for unwanted pain, infections, and further decrease in quality of life. […]

• No harm, potential for more than minimal, patternF842May 14, 2026

  Based on interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices on each resident that are complete and accurately documented for 1 of 5 (CR#1) residents reviewed for clinical records. The facility failed to maintain a complete and accurately documented clinical record for CR#1. This failure could place residents at risk of not getting the care and services to improve their quality of life due to not maintaining complete and accurate clinical records.Record review of CR#1's face sheet dated 5/14/2026 revealed the resident was admitted to the facility on [DATE]. […]