Sabine Heights Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sabine Heights Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF755Jun 17, 2024

  Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Resident #1) reviewed for pharmacy services. The facility failed to transcribe Resident #1's discharge orders dated 04/08/24 and failed to follow-up to ensure Resident #1's hospital discharge orders were implemented to include her Rivaroxaban (Xarelto-used to prevent blood clots). Resident #1 was not administered Rivaroxaban (Xarelto) for 38 days. […]

• Immediate jeopardy, patternF760Jun 17, 2024

  Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medication errors. The facility failed to administer Resident #1's Rivaroxaban (Xarelto-used to prevent blood clots) for 38 days (04/09/24 through 05/17/24). Resident #1's hospital discharge orders were not implemented to include her Rivaroxaban (Xarelto). Resident #1 was admitted to hospital on 05/17/24 and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure. An IJ was identified on 06/14/24 at 12:05 p.m. […]

• Immediate jeopardy, patternF580Oct 3, 2023

  Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); for 1 of 4 residents reviewed for notification. (Resident #1) The facility failed to consult with Resident #1's physician, when Resident #1's HIV (a virus that attacks the human immune system) medication Triumeq (a medication used to treat HIV; discontinuation or interruption of antiretroviral therapy (ART) may result in viral rebound, immune decompensation, and/or clinical progression) was not available for administration in August 2023 for 11 doses and September 2023 for 3 doses. […]

• Immediate jeopardy, patternF760Oct 3, 2023

  Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 4 residents reviewed for significant medication errors. (Resident #1) The facility failed to ensure Resident #1's HIV ([human immunodeficiency virus] a virus that attacks the human immune system) medication was available for administration in August 2023 for 11 doses and September 2023 for 3 doses. Resident #1 had a diagnosis of HIV. An Immediate Jeopardy (IJ) situation was identified on 10/02/23 at 4:24 p.m. […]

• Immediate jeopardy, isolatedF689Sep 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 7 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on 09/14/2025 and was located by facility staff approximately 50 feet off facility premises in a tall grassy area with rocks, uneven ground, and cut trees. An IJ was identified on 09/14/2025. The IJ template was provided to the facility on [DATE] at 4:10 p.m. While the IJ was removed on 09/19/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on Elopement. […]