Failure to Provide Timely Survey Information and Access
Summary
The facility failed to provide timely and required information to the survey team upon entry and during the annual recertification survey, affecting all residents. Upon arrival, the survey team leader requested a facility census, resident list, and matrix from an RN, but these were not provided. Subsequent requests for the same information, as well as WIFI access, were made to the DON and NHA, with the full set of documents and access not provided until over an hour after entry. The WIFI access provided did not function throughout the survey, further impeding the process. The entrance conference worksheet, which outlines the required timeframes for document provision, was sent to the NHA, and the entrance conference was conducted, with the NHA confirming familiarity with the electronic file sharing platform. Delays continued as the NHA reported not having full access to the clinical portions of the EMR, and the DON was new and still acclimating to the system. Additional required documents, such as hospice agreements and dialysis contracts, were not provided within the required timeframe and had to be requested again. The DON later acknowledged that any unit manager should have been able to provide a census upon surveyor entry and agreed that the survey team was not provided timely documentation upon entry.
Penalty
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The facility failed to provide immediate access to residents and records for an HHSC surveyor conducting a Priority One investigation, when the ADM refused entry and the surveyor was instructed to leave, causing a four-hour delay before the entrance conference and investigation began. The ADM later acknowledged acting between corporate staff and HHSC and reported there was no facility policy addressing impeding surveys or access to medical records. At the time, there were 93 residents in the facility, and governing body policy and state regulations required allowing HHSC representatives to enter and conduct necessary inspections and investigations.
An HHSC representative arrived at the facility to conduct a Priority One investigation and was instructed to wait in the lobby for the Administrator. When the Administrator arrived, he told the HHSC representative that they would need to send someone else because he had filed a complaint against that representative and that the resolution was that the representative would not be allowed back in the building. The HHSC representative subsequently left without conducting the investigation, despite state law and HHSC guidance allowing commission representatives to enter at reasonable times and requiring providers to grant surveyors access to records. Facility census records showed 123 residents were present at the time, and the report states that this failure placed all residents at risk of potential harm due to the P1 investigation not being conducted to rule out immediacy.
Facility staff did not consistently answer telephones, preventing residents and family members from contacting the facility. Multiple calls from the state agency, family members, and outside physicians went unanswered, with no option to leave a message. A resident and a family member both reported having to contact police due to lack of response from staff. Staff and the Ombudsman confirmed ongoing issues with phone access, and the administrator was unaware of recent problems.
A resident with ALS was unable to reach staff after her call light fell, and her family member's repeated phone calls to the facility went unanswered and unreturned. Interviews revealed that after-hours calls were not consistently answered or forwarded to residents, and two other residents also reported not receiving intended calls. The administrator acknowledged that calls should be answered and properly forwarded at all times.
The facility did not establish a structure to ensure compliance with resident rights, as no personnel were assigned to monitor this, and the policy used was hospital-based and not tailored to the facility. The policy was a 13-page document that included all resident rights statements without individualized mechanisms for compliance.
A facility failed to manage its phone system, leading to unanswered calls and communication breakdowns. This resulted in a resident not receiving Paxlovid for COVID-19 treatment for five days and a complainant unable to reach staff. The receptionist was unaware of the phone system's mailbox setup, and the facility's policy on phone answering was not effectively implemented.
Failure to Provide Immediate Access for Priority One State Investigation
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate access to residents for a state representative of HHSC conducting a Priority One (P1) investigation. On 03/03/2026 at 10:05 a.m., an HHSC surveyor entered the facility, checked in at the reception desk, and was taken to the conference room. At 10:11 a.m., the administrator entered the conference room and informed the surveyor that she would not be allowed into the building to conduct the P1 investigation, even after being advised that it was a P1 investigation. At 10:43 a.m., the surveyor was instructed by phone from the program manager to leave the facility. The program manager then contacted the associate regional director and briefed her on the incident. The surveyor was not allowed to re-enter and begin the entrance conference and P1 investigation until 2:00 p.m., resulting in a four-hour delay in surveyor access. During an interview on 03/03/2026 at 2:00 p.m., the administrator apologized for the situation and stated he was acting like a “ping pong ball” between corporate staff and HHSC. In a subsequent interview on 03/05/2026 at 12:30 p.m., the administrator stated the facility did not have a policy on impeding a survey or access to medical records. Review of the facility census showed there were 93 residents at the time. Review of the facility’s governing body policy indicated the governing body is responsible for establishing and implementing policies regarding management and operation of the facility. Review of state law (Health and Safety Code Ch. 242.043) and HHSC Provider Letter PL 18-26 confirmed that HHSC or its representatives may enter an institution at reasonable times to conduct inspections, surveys, or investigations and that providers must grant access to records, underscoring that the administrator’s refusal and the resulting delay were contrary to these requirements.
Administrator Denies HHSC Surveyor Immediate Access for Priority One Investigation
Penalty
Summary
The deficiency involves the facility’s failure to allow immediate access to residents by a state representative of the Texas Health and Human Services Commission (HHSC) who arrived to conduct a Priority One (P1) investigation. On the morning in question, at about 8:55 a.m., an HHSC representative arrived at the facility and was instructed to wait in the lobby for the Administrator. At approximately 9:04 a.m., the Administrator came to the lobby and told the HHSC representative that they would have to send someone else because the Administrator had filed a complaint against that representative. The Administrator further stated that the resolution to his complaint was that the HHSC representative would not be allowed back in the building. Subsequent observation at about 9:47 a.m. showed the HHSC representative leaving the facility’s parking lot without having been allowed to conduct the P1 investigation. Census records reviewed by surveyors showed that there were 123 residents in the facility on that date. Record review of Texas Health and Safety Code Chapter 242, Section 242.043, indicated that the commission or its representative may enter an institution at reasonable times to conduct inspections, surveys, or investigations as necessary. Review of HHSC Provider Letter PL 18-26 stated that providers must grant access to all electronic health records when requested by a surveyor. The report states that this failure to allow entry placed all 123 residents at risk of potential harm due to a P1 investigation not being conducted to rule out immediacy.
Failure to Ensure Telephone Access for Residents and Families
Penalty
Summary
Facility staff failed to ensure that residents and family members could reliably contact the facility via telephone. Multiple attempts by the state agency to reach the facility by phone on several occasions went unanswered, and there was no option to leave a message. Interviews with staff, the Ombudsman, family members, and residents confirmed ongoing issues with unanswered calls. A registered nurse acknowledged that phones sometimes went unanswered, especially during periods of short staffing, and the Ombudsman reported receiving complaints from families about this issue. Family members described repeated unsuccessful attempts to contact the facility, including one instance where a family member had to involve the police for a wellness check due to lack of response. Outside physicians also reported being unable to reach facility staff. A resident reported that after waiting 90 minutes for a response to his call light, he attempted to call the facility for assistance but received no answer, ultimately contacting the police for help. The administrator was aware of previous concerns but was not aware of the specific phone system issues on the dates in question. These findings indicate that the facility did not provide immediate access to residents as required, affecting the ability of residents and their families to communicate with staff and receive timely assistance.
Failure to Ensure Timely Response to Resident Telephone Calls
Penalty
Summary
The facility failed to ensure that telephone calls for a resident were answered by staff, resulting in a lack of immediate access to the resident. During an unannounced visit, it was found that a resident with ALS, a progressive neurodegenerative disease, was unable to use her call light after it fell to the floor. She called out for assistance but received no response from staff. The resident then contacted a family member for help. The family member reported making multiple unsuccessful attempts to reach facility staff by phone over an 11-minute period, eventually being transferred to the nurses' station without the call being answered or receiving a callback. Interviews with facility staff revealed that after the receptionist left at 9 p.m., incoming calls were transferred to the Registered Nurse Supervisor, who stated that calls might not be answered immediately if she was attending to resident care. Additional interviews with two other residents indicated that calls intended for them were also not forwarded. The administrator confirmed that the expectation was for calls to be answered and forwarded appropriately during and after office hours.
Failure to Ensure Resident Rights Compliance
Penalty
Summary
The facility failed to establish a structure to comply with the resident's right to provide immediate access to any representative of the State, the resident's individual physician, or any representative of the protection and advocacy systems. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Communication Breakdown Due to Unanswered Phones
Penalty
Summary
The facility failed to ensure proper access to residents by not adequately managing their phone system, which resulted in significant communication breakdowns. The phones in the facility were left unanswered, preventing a pharmacy from contacting nursing staff to clarify a physician's medication order. This led to a resident not receiving Paxlovid, a medication for treating mild-to-moderate COVID-19, for five days. Additionally, a confidential complainant was unable to reach staff to discuss an urgent matter due to the facility's phone system issues. The deficiency was observed when the facility's phone rang multiple times without being answered, eventually rolling over to a message system. The receptionist, who was responsible for answering calls during business hours, was unaware of the phone system's mailbox setup. The facility's phone system was new and rang throughout the facility, but neither the Administrator nor the Maintenance Director was aware that calls rolled over to a mailbox after a certain number of rings. The facility's policy indicated that phones should be answered from the business office or nurses' station, but this was not effectively implemented, leading to the communication failures.
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