Mont Belvieu Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Mont Belvieu Rehabilitation & Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF635Oct 13, 2022

  Based on observation, interview, and record review the facility failed to complete and accurate admission orders for the resident's immediate care for 2 of 19 residents reviewed (CR #138, and Resident #241). *The facility failed to ensure Resident CR#138, a new admission with a diagnosis of diabetes was provided with a physician's order for insulin or blood sugar checks. The facility did not receive any intervention until resident family intervened on 09/15/22 (6 days after admission). Resident CR#138's blood sugar on 09/15/22 was 528 mg/dl. * The facility failed to ensure Resident #241's hospital discharge medication order for Betapace (anti-arrhythmic med used to treat a-fib) was transcribed and followed. […]

• Immediate jeopardy, isolatedF600Oct 4, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents' right to be free from abuse and neglect for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to provide incontinent care to Resident #1 for more than 8 hours on 09/24/23. Resident #1 sustained excoriation (injury to the skin), swollen labia, and a blister to her peri-area (delicate portion of skin between your genitals and anus). An Immediate Jeopardy (IJ) situation was identified on 09/28/23 at 1:43 p.m. […]

• Immediate jeopardy, isolatedF677Oct 4, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 10 residents (Resident #1) reviewed for ADL care. The facility failed to provide incontinent care to Resident #1 for more than 8 hours on 09/24/23. Resident #1 sustained excoriation (injury to the skin), swollen labia, and a blister to her peri-area (delicate portion of skin between your genitals and anus). An Immediate Jeopardy (IJ) situation was identified on 09/28/23 at 1:43 p.m. […]

• Immediate jeopardy, isolatedF607Aug 16, 2023

  Based on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after Resident #1 was found deceased on the floor of her bathroom with injuries of unknown origin. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. […]

• Immediate jeopardy, isolatedF610Aug 16, 2023

  Based on interview and record review the facility failed to thoroughly investigate and take measures to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation was in process, and failed to ensure corrective action was taken for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to investigate allegations of abuse and neglect and ensure corrective actions were in place after Resident #1 was found deceased on the floor of her bathroom, with injuries of unknown origin. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. […]