Garden Terrace Healthcare Center Of Houston

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for Resident #5 that included measurable objectives and timeframes to meet his medical, nursing, mental, and psychosocial needs. Resident #5 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting his right dominant side, difficulty walking, generalized muscle weakness, bilateral primary osteoarthritis of the hip, and a urinary tract infection. His MDS reflected a BIMS score of 12, indicating moderate cognitive impairment, and he was coded for use of a wheelchair and walker, with total dependence for toileting and showering. Resident #5’s care plan dated 05/21/2026 included interventions for max assist with transfers using a gait belt and assistance with mobility and ADLs as needed, as well as two-person assist for all transfers due to an actual fall related to weakness and poor balance. His Kardex dated 05/22/2026 also reflected max assist with transfers with a gait belt. Despite these documented care needs, on 05/22/2026 the resident was transferred from his wheelchair to his bed without a gait belt and without the required two-person transfer being carried out. During the observed transfer, CNA M pulled on Resident #5’s right arm and assisted him primarily by holding his arm while he pushed up with his left side. LVN G was present, held the wheelchair, and assisted with the resident’s pants, but was not observed assisting with the physical transfer. A gait belt was hanging on the resident’s dresser door. CNA M stated she did not see a gait belt and was not aware the resident was a two-person assist. LVN G stated she knew the resident should have used a gait belt and knew he was a two-person assist, but she did not assist throughout the transfer. The ADON and MDS Coordinator both stated the transfer did not follow the resident’s care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #5’s environment remained free from accident hazards and that he received adequate supervision and assistance devices during transfers. Resident #5 was a male with hemiplegia and hemiparesis following a cerebral infarction affecting his right dominant side, difficulty walking, generalized muscle weakness, bilateral primary osteoarthritis of the hip, and a urinary tract infection. His MDS reflected a BIMS score of 12, indicating moderate cognitive impairment, and he was coded for use of a wheelchair and walker. His care plan and Kardex identified him as requiring max assist with transfers with a gait belt, and his care plan also included two-person assist for all transfers due to weakness and poor balance. On observation, CNA M transferred Resident #5 from his wheelchair to bed without using a gait belt. CNA M assisted him by placing her arm under his right arm and guiding him primarily by holding his right arm, while Resident #5 pushed up with his left side. LVN G was present and assisted only by holding his pants and wheelchair. A gait belt was observed hanging on the resident’s dresser door but was not used during the transfer. During interview, CNA M stated she did not see a gait belt in the room and acknowledged she could have hurt Resident #5 if she had not used one. LVN G stated she knew Resident #5 was a two-person assist and that not using a gait belt could lead to resident and staff injuries, but she did not assist throughout the entire transfer. The ADON stated that a one-person transfer without a gait belt was not safe and did not follow the resident’s care plan. The MDS Coordinator stated staff were expected to follow the care plan and that staff should know to read and follow the plan. Facility policy for transferring residents with one-sided weakness or diminished lower-body sensation reflected that transfer may initially require partial support to full assistance by at least two people, and the gait belt policy stated the facility would provide gait belt use in accordance with professional standards of practice. The report documented that staff did not follow Resident #5’s transfer plan during the observed transfer.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate treatment and services for a resident who was incontinent of bladder to help prevent urinary tract infections. Resident #5 was a male with hemiplegia and hemiparesis following a cerebral infarction affecting his right dominant side, difficulty walking, generalized muscle weakness, bilateral primary osteoarthritis of the hip, and a recent UTI. He was coded as totally dependent on staff for toileting and showering, and his record showed an abnormal urine culture positive for E. coli, with physician orders for antibiotics and later a change to Bactrim for 20 days after the urologist discontinued nitrofurantoin. Progress notes also documented continued pain related to the UTI during the shift on 05/17/2026. During observation of incontinent care, CNA M and LVN G were observed providing care without changing gloves and sanitizing their hands between tasks while cleaning Resident #5's penis. LVN G touched the trash can with her gloves and used the same gloves to remove the resident's brief without removing gloves or sanitizing hands in between. CNA M used wipes to clean the resident's penis, then used the same soiled gloves to grab more wipes, changed gloves multiple times without proper hand hygiene, wiped the resident again, and used soiled gloves to grab baby powder. Both staff members used dirty gloves to pull on the resident's clothes, touched the wheelchair, the resident's shoes, and pulled back the curtain. A hand sanitizer dispenser was present in the room, but neither staff member was observed using it. Both CNA M and LVN G acknowledged that hand sanitizing between glove changes was necessary and that failing to do so could spread infection.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to keep resident-identifiable information confidential and to safeguard medical record information against unauthorized use for 1 of 5 residents observed for privacy. On 05/22/2026, RN V left Resident #2’s empty Gabapentin blister pack on a medication cart near the nurse’s station where it could be seen by anyone walking by. The blister pack was observed stuck between binders in the open on the cart and contained Resident #2’s name and medication number. RN V later retrieved it and stated she had been gathering empty blister packs for multiple residents to shred at once, but had answered a call light and forgot to return for the pack. She stated it should not have been left out and that anyone could get resident information from it. Resident #2’s record showed she was an [AGE] year-old female admitted with diagnoses including acute respiratory failure with hypoxia, muscle weakness, malignant neoplasm of the left breast, and chronic kidney disease. Her physician’s order summary reflected an active order for Gabapentin 300 mg by mouth daily for neuropathy. The ADON and Administrator both stated that leaving medication information in public view was not acceptable and was a HIPAA violation, and the facility’s Notice of Privacy Practices stated the facility is required to maintain the privacy of health information.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one resident observed for infection control. During observation on 05/21/2026, a breakfast tray with oatmeal, eggs, and liquids was left in an open dining area behind the nurse's station, and CNA L stated it should not have been there because it could be a cross-contamination issue and removed it toward the kitchen. Resident #5 was a male admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, difficulty walking, generalized muscle weakness, bilateral primary osteoarthritis in the hip, and a urinary tract infection with onset date 05/06/2026. His MDS reflected a BIMS score of 12, indicating moderate cognitive impairment, and he was coded as wheelchair and walker dependent and totally dependent on staff for toileting and showering. His care plan included interventions for the urinary tract infection, including checking for incontinence at least every two hours, washing, rinsing, and drying soiled areas, and giving antibiotic therapy as ordered until 05/26/2026. On 05/22/2026, observation showed LVN G and CNA M providing incontinent care without changing gloves and sanitizing hands between tasks. LVN G touched the trash can with gloves and used the same gloves to remove the resident's brief without removing gloves or sanitizing hands. CNA M cleaned the resident's penis, then used the same soiled gloves to grab more wipes, changed gloves multiple times without proper hand hygiene, and later used soiled gloves to grab baby powder. Both staff members used dirty gloves to pull on the resident's clothes, touch the wheelchair, shoes, and curtain. The room had a hand sanitizer dispenser that was empty, and neither staff member used it during care. Interviews confirmed that not using hand sanitizer between glove changes was not acceptable practice and could lead to infections.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement a person-centered baseline admission care plan within 48 hours of admission for one resident. The resident was an elderly female with a history of a lower radius fracture, hypertension, and dementia, and her 15-day MDS showed a BIMS score of 0/15, indicating severely impaired cognition, and a need for extensive to total assistance with ADLs. Record review showed that her existing care plan had been canceled when she was sent to the hospital, and upon readmission, no new baseline care plan with goals, interventions, treatments, and psychosocial needs was created. The only new entry on the care plan after readmission was a full code status entered by the ADON, despite an out-of-hospital DNR form later being dated the day before the resident was discharged back from the hospital. Interviews with staff revealed multiple process failures related to the baseline care plan and code status. The MDS Coordinator stated she did not know who canceled the original care plan and explained that when residents go to the hospital, orders are discontinued and the care plan is marked canceled. She reported that the admitting nurse should have initiated the baseline care plan UDA upon readmission, which would have triggered the comprehensive care plan, but this did not occur. The DON confirmed that the baseline care plan UDA did not trigger and attributed questions about this to the electronic system, and also stated that social work uploaded the DNR paperwork but did not notify nursing so the code status could be changed from full code to DNR. The ADON acknowledged manually entering full code without having the out-of-hospital DNR at that time and stated she was unaware of the DNR when she did so. Facility policy indicated that completion and implementation of a baseline care plan within 48 hours of admission is intended to promote continuity of care, communication, and resident safety, underscoring that this required process was not followed for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that pharmaceutical services and controls for a liquid controlled medication were accurate and consistent for one resident. The resident was an adult male with diabetes mellitus, hypertension, and cerebral infarction, with moderately impaired cognition (BIMS score 10/15) and requiring extensive to total assistance with ADLs. His physician’s order and April 2026 order summary showed Lacosamide oral solution 10 mg/mL, 5 mL twice daily for epilepsy, ordered on 03/17/26. The controlled substance count sheet for this Lacosamide listed 45 mL on hand, and the MAR showed the last documented administration as the morning of 04/02/26 by an LVN. On 04/02/26, during inspection of the medication cart with the ADON and the LVN, surveyors observed that the Lacosamide bottle contained approximately 65 mL, while the control count sheet reflected only 45 mL. The ADON stated that this medication usually came overfilled and acknowledged that the facility did not correct the count to match the actual volume in the bottle. She reported she could not determine how much the bottle was overfilled compared to the 180 mL listed on the label and the amount on the count sheet, and she did not verify the discrepancy using the measurement lines on the bottle when prompted. She also stated that a mismatch between the liquid medication and the count sheet could be considered drug diversion and that none of the nurses had informed her of the discrepancy. The LVN who administered the medication stated that the bottle had more medication than what was documented on the count sheet and acknowledged that, as a nurse, she should have reported such a discrepancy to the DON and ADON but did not do so, assuming another nurse had reported it. She indicated that nurse management had told staff that liquid medications sometimes came with more medication than written on the bottle and that the DON and ADON were supposed to verify counts of liquid controlled medications, though she was unsure of their exact responsibilities. The DON later stated that the Lacosamide may have come overfilled and that nurses would continue to administer the medication until the labeled quantity was given and then destroy any overage, and she acknowledged that a discrepancy between the control count sheet and the actual medication could be drug diversion. The facility’s drug diversion prevention policy required incoming and outgoing nurses to count all controlled substances and reconcile the number of doses on hand with the controlled substance count sheet and the MAR, which was not done in this case.

Penalty

Inspection fine: $32,819

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and appropriate respiratory care for a resident requiring tracheostomy care and tracheal suctioning, as ordered by the physician and consistent with professional standards of practice. Specifically, staff did not perform the prescribed trach care, including changing the trach aerosol tubing, mask, jet nebulizer bottle, water trap, and trach ties according to the schedule outlined in the physician's orders. Documentation in the Treatment Administration Records (TAR) for multiple dates showed that these tasks were not completed as required, and staff interviews confirmed that some care was either not performed or not documented. The facility's own policy required daily and PRN tracheostomy care using sterile technique, but this was not consistently followed. The resident involved had significant medical needs, including lymphoma, immunodeficiency, dysphagia, and a tracheostomy, and was dependent on staff for respiratory care. Observations and interviews revealed that the resident produced large amounts of thick mucus, required frequent suctioning, and was at increased risk for infection due to his immunocompromised status. Despite these needs, there were repeated failures to change respiratory equipment and trach ties as ordered, and staff could not consistently explain or document when or if these tasks were performed. The resident was eventually admitted to the hospital with brown emesis from the mouth and trach, and was diagnosed with MRSA bacteremia. Hospital staff noted that the trach had not been changed in a long time. Interviews with nursing and respiratory staff indicated a lack of clarity and follow-through regarding the completion and documentation of trach care. Some staff admitted to not documenting care, while others were unaware of discontinued orders or the reasons for missed care. The resident himself communicated that staff did not change the equipment as ordered, attributing it to staff not wanting to do the work. The DON was unaware of several missed or discontinued orders and did not follow up after the resident's hospital admission. These failures were identified through observation, interview, and record review, and resulted in an Immediate Jeopardy finding.

Removal Plan

• Identified resident was transferred to the hospital for further evaluation and treatment.
• The identified resident will be re-admitted if orders for such.
• Education will be completed regarding following physician orders for trach care to include changing trach aerosol tubing, mask, nebulizer bottle, water trap, trach ties and trach color as ordered.
• This education will be provided to current licensed nursing staff by the Director of Nursing/Respiratory Therapist and/or Regional Nurse Consultant.
• This training will be provided prior to staff working.
• Licensed staff will not provide direct care to residents until training is completed.
• Divisional Clinical Nurse reviewed facility's policy and procedures for tracheostomy care. No changes made.
• No new patients/residents requiring tracheostomy care/tracheal suctioning will be admitted until 100% of licensed staff have been trained and deemed competent.
• Two additional residents requiring respiratory/tracheostomy care and tracheal suctioning will be seen by the attending physician, or medical director to ensure no negative assessment findings.
• DON/Designee conducted an audit of current residents and tracheostomy supplies to validate trach supplies were available at bedside.
• The Director of Nursing will begin immediate in-servicing of LVN A, RN B, and LVN C, on the following: Completion and documentation of physician ordered tracheostomy care; Return demonstration of trach care w/competency documented.
• Licensed staff will ensure that the orders for trach care will include changing trach aerosol tubing, mask, nebulizer bottle, water trap, trach ties and trach collar as ordered.
• DON/designee will review MARs/TARs daily to validate trach care orders are carried out.
• LVN A, RN B, and LVN C staff will not be allowed to begin their shift until they have received the education/competency as noted above.
• Licensed weekend staff will be provided with 1:1 re-education on care for patients with tracheotomies. The education will include competency for tracheal care, suctioning, tubing changes, and documentation.
• The Director of Nursing, Assistant Director of Nursing or Regional Nurse Consultant will complete the following until substantial compliance has been met and achieved: Daily audits of residents requiring respiratory/tracheostomy care and tracheal suctioning will be reviewed to ensure that physician orders for such are documented.
• The facility will continue to provide the in-servicing as noted above to newly hired licensed staff, annually and as needed.
• The Director of Nursing or Assistant Director of Nursing will audit licensed nurses training and competency records to ensure tracheostomy care/tracheal suctioning training compliance.
• Nurse Managers will round on trach patients on weekends to validate trach care performed and there are no signs/symptoms of infection. Any issues identified will be addressed immediately.
• All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made until substantial compliance has been achieved.
• The Director of Nursing, Assistant Director of Nursing and Regional Nurse Consultant is responsible for the corrections and continued monitoring.
• The Medical Director was notified and agrees with the plan of removal.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide and document adequate preparation and orientation for the safe and orderly transfer or discharge of two residents. For one resident, the discharge summary was incomplete, lacking essential information such as a recapitulation of the stay, physical assessment, discharge instructions, and signatures from the resident, their representative, or transportation service. Additionally, there was no documentation in the electronic medical record regarding the resident's discharge on the day it occurred, including details about the mode of transportation, diet, discharge vitals or assessment, or education provided. For the second resident, the discharge summary was also incomplete, with the recapitulation of the stay left blank and no signature from the resident or their representative. The summary only indicated that the resident was discharged home with a family member, without further required details. Interviews with staff confirmed that discharge summaries and progress notes were expected to be completed by the interdisciplinary team (IDT) and provided to the resident, their family, or the receiving facility, but this process was not followed for these residents. Furthermore, the administrator acknowledged that the ombudsman was not notified of the residents' discharges, despite being aware of the regulatory requirement to do so. The facility's policy requires comprehensive documentation and communication during transfers or discharges, including providing necessary information to the receiving provider and appropriate notifications, but these steps were not completed as required for the two residents involved.

Penalty

Inspection fine: $54,094

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate care to prevent and treat pressure ulcers for a resident, leading to the deterioration of a sacral wound from a stage III to a stage IV pressure ulcer. The resident, an eighty-year-old woman with multiple health conditions including Myasthenia Gravis, Type 2 Diabetes, and hypertension, was admitted to the facility with a history of pressure ulcers and was at mild risk for developing new ones. Despite this, the facility did not implement appropriate interventions to manage her urinary incontinence and moisture-associated skin damage, which contributed to the worsening of her condition. The facility's staff did not follow the prescribed wound care treatment orders, which included the application of Santyl/calcium alginate and zinc oxide, and the use of a low air mattress for wound stabilization. There was a lack of communication and coordination among the staff, as evidenced by the failure to update treatment orders in the system and the absence of a low air mattress until much later. The wound care nurse, who was new to the position and inadequately trained, continued with outdated orders, and the resident's wound care was not consistently managed, leading to fecal contamination and further deterioration of the wound. Interviews with staff revealed a lack of awareness and responsibility regarding the resident's wound care needs. CNAs reported frequent bowel movements and saturated bandages, but there was no consistent follow-up or action taken by the nursing staff. The wound care nurse and other staff members were not adequately informed or trained to handle the resident's condition, resulting in a failure to maintain the cleanliness and integrity of the wound. This negligence ultimately led to the resident being admitted to the hospital with a diagnosis of sepsis, highlighting the severe impact of the facility's deficiencies in providing appropriate care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to the planned menus for three meal services, affecting all 36 residents. On two consecutive days, the meals served did not match the posted menus. For instance, on the first day, the lunch menu listed garlic pepper pork loin with gravy, seasoned beans, and other items, but residents were served baked ham, diced beets, and cheesecake instead. Similarly, on the second day, the lunch menu listed turkey tetrazzini and other items, but spaghetti and mixed vegetables were served. The dinner menu also did not match the posted menu, with lemon pepper fish being served instead of the planned western egg bake. The discrepancies in meal service were attributed to the absence of the kitchen manager, who was on medical leave. An interim dietary manager from a sister facility was filling in but was only present part-time. The interim manager acknowledged that the staff was not accustomed to following the menu and that there was no dietitian on staff to approve menu changes. The interim manager was aware of the issue and was working on improving adherence to the menu, but the lack of consistent oversight and staffing challenges contributed to the failure to follow the planned menus.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for a resident with a gastrostomy tube, leading to potential complications. Resident #11, who is in a persistent vegetative state and dependent on others for all activities of daily living, was observed with redness and dried red drainage around the gastrostomy tube site. Despite the presence of redness, the facility staff did not adequately address the condition, as evidenced by the lack of documentation and communication regarding the changes in the resident's condition. Observations revealed that the redness around the gastrostomy tube site was not reported to the physician or adequately documented by the nursing staff. Interviews with various staff members, including LVNs and RNs, indicated a lack of consistent monitoring and communication about the resident's condition. The night shift was responsible for dressing changes, but there was no report of the redness to the day shift or the physician, leading to a delay in addressing the issue. The facility's policy required documentation and monitoring of the gastrostomy tube site, but this was not followed. The Director of Nursing and other staff members acknowledged the need for proper documentation and communication of any changes in the resident's condition. The failure to adhere to these protocols placed the resident at risk of infection and other complications associated with improper gastrostomy tube care.