Spindletop Hill Nursing And Rehabilitation Center

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 the medication error rate remained below 5 percent. Surveyors identified a 26.67% medication error rate, based on 8 errors out of 31 opportunities, involving 3 residents and 3 staff members observed during medication administration. The errors included incorrect doses of ferrous sulfate for one resident and multiple medication dose discrepancies for another resident, as well as an error involving a third resident’s enteral medication administration. One resident with a history of cerebral infarction, muscle wasting, constipation, hypertension, and mixed hyperlipidemia had a physician order for ferrous sulfate 326 mg by mouth daily. During observation, MA I administered ferrous sulfate 325 mg instead. The resident had severely impaired cognition, with a BIMS score of 3 out of 15. During interview, MA I stated she did not notice the milligram difference and acknowledged she was responsible for ensuring the dosage was correct before administration. Another resident with osteomyelitis, muscle wasting, and anemia had orders for ferrous gluconate 324 mg, magnesium oxide 250 mg, vitamin C 1000 mg, folic acid 1000 mcg, and methocarbamol 1000 mg. During observation, MA F administered ferrous gluconate 325 mg, magnesium oxide 240 mg, vitamin C 500 mg, folic acid 400 mcg, and methocarbamol 500 mg. A third resident with cerebral infarction, dysphasia, and abdominal pain had an order for MiraLAX via G-tube and water flushes before and after medication administration. During observation, LVN N used another resident’s MiraLAX bottle, mixed it with water, and administered it without the ordered 50 cc water flush before medication administration.

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 establish and maintain an infection prevention and control program for two residents observed for infection control. One deficiency involved a wound care nurse who provided wound care to a resident with diabetes mellitus, end stage renal disease, dependence on renal dialysis, and cerebral infarction, and who had a sacral abscess with orders for cleansing, betadine, and a gauze island dressing. During observation, the nurse cleaned a bedside table, set up supplies, entered the room, washed her hands, applied a gown and gloves, and began wound care. After removing gloves during the procedure, she did not perform hand hygiene before putting on new gloves, and this occurred multiple times while she continued the wound care and adjusted the resident in bed. A second deficiency involved a resident with severe cognitive impairment, dysphagia, major depression, cerebral infarction, and a gastrostomy tube who had Enhanced Barrier Precautions ordered and documented in the care plan and physician orders. During observation of perineal/incontinent care, two CNAs provided direct care to the resident without wearing gowns, despite PPE being available outside the room and signage indicating the precaution. Both CNAs stated they forgot to wear a gown during the care and acknowledged they had been trained on Enhanced Barrier Precautions. The record also showed facility policies for hand hygiene and Enhanced Barrier Precautions. The hand hygiene policy stated that gloves do not replace hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them. The Enhanced Barrier Precautions policy stated that gowns and gloves are required for high-contact resident care activities for residents with wounds or indwelling medical devices, including feeding tubes, and listed changing briefs or assisting with toileting as high-contact care activities.

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 an allegation of abuse involving Resident #80 was reported to HHSC within the required timeframe. Resident #80 was a female resident with diagnoses including cerebral infarction (stroke), lack of coordination, and anxiety disorder. Her quarterly MDS indicated she could make herself understood and understand others, and her BIMS score was 15/15, showing she was cognitively intact. Her care plan noted a behavior problem with interventions to protect the rights and safety of others, speak in a calm manner, divert attention, and remove her from the situation as needed. Record review showed the allegation involving Resident #80 was learned about at 1:00 p.m. on 08/03/2026, but it was not reported to HHSC until 5:04 p.m. the same day. The provider investigation report stated Resident #80 alleged that CNA P had bullied her sometime during the prior week, around 6:30 p.m. during a smoke break, though she could not recall exactly what was said or the setting. During an interview, the Administrator stated he initiated the investigation at 1:00 p.m. and acknowledged the allegation should have been reported within 2 hours. CNA P stated she was not the resident’s assigned CNA and said she had helped push Resident #80’s wheelchair after a smoke break when the resident accused her of trying to push her out of the wheelchair.

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 the MDS accurately reflected Resident #2’s PASRR status. Resident #2 was admitted with diagnoses including major depressive disorder, stroke, hemiplegia/hemiparesis following stroke, and anxiety disorder. Her annual MDS dated 03/13/2026 coded PASRR A1500 as 0, indicating no ID/DD-related PASRR conditions, even though the record showed she had been determined PASRR positive for mental illness on her Level 1 screening and subsequent PASRR service plan documents. Her care plan also did not identify PASRR positive status or related interventions, despite documentation that she received MI specialized services and attended quarterly PASRR meetings. The facility also failed to accurately complete Resident #48’s MDS regarding insulin injections. Resident #48 was admitted with diagnoses including osteomyelitis, hypertension, and GERD, and her admission record did not show diabetes. Her MDS completed on 06/23/2026 indicated that she received insulin injections, but the care plan, MAR, and physician orders did not show any insulin orders. During interview, Resident #48 stated she had no history of diabetes and had never taken insulin, reporting only blood thinner injections while in the facility. The MDS Coordinator confirmed the insulin entry was a data entry error and stated it should have been coded as zero. Interviews with the MDS Coordinators, DON, and Administrator confirmed that MDS completion and accuracy were assigned to the facility’s MDS staff and reviewed by the Regional MDS Coordinator. The MDS Coordinators stated that Resident #2 was PASRR positive and that the annual MDS was incorrect, and they acknowledged that Resident #48’s insulin coding was entered incorrectly. The Administrator stated the facility used the RAI Manual for guidance and expected all MDSs to be correct and accurate, while the DON stated an incorrectly marked MDS may not reflect the resident’s accurate care needs.

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 a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one resident with PASRR positive status for mental illness. Resident #2 was admitted and readmitted with diagnoses including major depressive disorder, stroke with hemiplegia and hemiparesis, and anxiety disorder. Her annual MDS dated 03/13/2026 showed a BIMS score of 10, indicating moderate cognitive impairment, and the MDS Section A1500 was coded as no ID/DD-related PASRR condition. However, record review showed she had been PASRR positive for mental illness since a Level 1 screening dated 07/24/2025 and had a PASRR Comprehensive Service Plan dated 08/27/2025 showing she received MI specialized services. The resident’s care plan updated on 07/08/2026 addressed antipsychotic medication use for major depressive disorder with monitoring and reporting interventions, but no care plan identified her PASRR positive status or included interventions related to PASRR services. During interviews, the resident and family stated she had been PASRR positive since admission, attended quarterly PASRR meetings, and received MI specialized services. MDS Coordinator A, MDS Coordinator B, the DON, and the Administrator all stated the care plan should reflect PASRR positive status and be reviewed and revised by the IDT, and they acknowledged the annual MDS and comprehensive care plan were not accurate.

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 residents who were unable to perform activities of daily living received the necessary services to maintain grooming and personal hygiene for two residents who needed assistance with facial hair removal. Resident #16 had diagnoses including multiple sclerosis, lack of coordination, need for assistance with personal care, muscle wasting, epilepsy, and blindness in the right eye. Her MDS indicated she had intact cognition, severely impaired vision, required staff assistance with personal hygiene, and needed help with personal care. Her care plan identified an ADL self-care performance deficit and stated she required limited assistance from one staff member with personal hygiene and oral care. During observations on multiple days, Resident #16 was seen with long facial hair on her chin. During an interview, she stated she wanted the hair on her chin shaved, said she depended on staff to shave her because she could not see well, and reported staff used to shave her once a week but had stopped. She said she wanted to be shaved regularly so her chin hair would not be noticeable and so she would look presentable when attending bible study. Staff interviews confirmed that she required assistance with shaving and that CNAs and nurses were responsible for ADL care and personal hygiene, including shaving. Resident #17 had diagnoses including cerebral infarction, hemiplegia, hemiparesis, need for assistance with personal care, muscle wasting, lack of coordination, and bilateral above-the-knee amputations. Her MDS indicated severe cognitive impairment, impaired vision, and a need for maximum assistance with personal hygiene. Her care plan stated she required maximum assistance from one staff member with personal hygiene and oral care. During repeated observations, she was seen with thick, long facial hair above her upper lip and on her chin. She answered yes when asked if she wanted her facial hair shaved, and staff interviews confirmed she had not been shaved for a while despite needing assistance. The DON and Administrator stated the residents had no history of refusing shaving and that staff were responsible for providing this 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 ensure that drugs and biologicals were stored in locked compartments and kept secure for 2 of 4 medication carts reviewed. During an observation on 08/04/2026 at 1:25 p.m. in the memory care unit, a small white round pill with a “49” imprint was found on the floor in front of the memory care medication cart while LVN E was checking meal tickets. LVN E picked up the pill, searched for it on her phone, and identified it as hydroxyzine 25 mg, an anti-itch medication. She stated she had just administered an anti-itch medication to a resident prior to lunch and verified the resident swallowed the medication, but she was unsure where the pill on the floor came from. At the time of the observation, 12 memory care residents were seated and eating lunch, and 2 residents were independently ambulatory. LVN E stated it was her responsibility to ensure medications were stored and locked in the medication cart and that medications should not be unsecured or on the floor around the cart before, during, or after administration. She also stated the pill may have been on the floor for 15 to 20 minutes and that only 2 residents in memory care had the physical mobility and dexterity to pick up a small pill from the floor. During a separate observation on 08/05/2026 from 9:40 a.m. to 9:43 a.m., MA F’s Hall 100 medication cart was observed unsecured with the keys left in the keyhole and the cart unattended while MA F was in a resident’s room. Drawer #1 contained OTC aspirin, vitamins, minerals, and eye drops, and Drawer #2 contained a locked compartment with controlled substances and multiple residents’ medication packets. MA F stated the cart should have been locked and that she should not have left the keys in the lock. The DON and Administrator later stated that medication carts should be kept locked and medications should not be left unattended on the cart or on the floor near the cart.

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 essential kitchen equipment in safe operating condition when the back center burner on the gas stove did not ignite when the knob was turned. During an observation and interview, the burner was checked and found not to light, and staff reported it had not been lighting for about 1 to 2 months. No gas odors or hissing sounds were observed in the kitchen, and the burner was later taken out of service until repaired. Staff interviews showed that cooks were expected to notify the DM when equipment was not working properly, and the DM was expected to notify the Maintenance Director and enter the concern into the electronic Maintenance reporting system. The Regional Director of Dietary Services stated the issue may have involved miscommunication between dietary and maintenance departments and said all dietary staff were educated to notify the DM with any equipment not working properly. The DM stated she had worked on the stove previously and thought the pilot light had gone out, while the Maintenance Director said he was not aware of the problem until it was brought to his attention. On a later observation, the same back middle burner still did not light immediately. A cook stated she was unsure whether water from eggs may have put out the pilot and said she had last seen it working a few days earlier. The Administrator stated he had only just been made aware that the stove had a burner not working, and the Maintenance Director had checked it and ordered a part to repair it. Record review also showed kitchen rounds documentation indicating the stove and oven were clean and equipment well maintained, along with facility policy stating that all staff should utilize the electronic Maintenance reporting system and that equipment repairs must be documented with a work order associated with the asset.

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 include mandatory QAPI training as part of its QAPI program for 1 of 23 staff reviewed, MA F. Record review showed MA F had a rehire date of 01/02/2024, and the facility’s training log showed no evidence that MA F completed QAPI training. Review of the training log for the previous 12 months, provided by human resources and the nursing department, also showed no evidence of QAPI training for MA F. During interviews, HR G stated annual required training was computer generated quarterly and staff received recurring emails about required completion and delinquent courses. HR G said completion was reported to department heads during weekday stand-up meetings, but only percentages of completion were reported, not delinquent staff. HR G stated employees were assigned training quarterly and it was the employee’s responsibility to complete training timely, including QAPI in the last quarter of the year. HR G acknowledged she should have monitored employees who were not completing training timely and reported delinquent staff for appropriate disciplinary action. HR H, the DON, and the Administrator stated HR was responsible for reporting staff completion of annual computerized training, and they said there was no policy regarding required annual QAPI training. They also stated staff were assigned computer-generated training quarterly, department heads were responsible for ensuring completion, and delinquent staff should be held accountable, including being removed from the schedule until training was completed.

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 required Ethics training for 1 of 23 staff reviewed for licensure and training, identified as MA F. Record review showed MA F had a rehire date of 01/02/2024, and the training log for the previous 12 months showed no evidence that MA F completed ethics training. During interview, HR G stated annual required training was computer generated quarterly, staff received recurring emails about required and delinquent courses, and completion percentages were reported during weekday stand-up meetings, but delinquent staff were not specifically reported. HR G also stated she should have monitored employees who were not completing training timely and reported delinquent staff to department heads for disciplinary action. During interviews, HR H, the DON, and the Administrator stated the HR department was responsible for reporting staff completion of annual computerized training, while department heads were responsible for ensuring staff completed assigned training. HR H stated there was no policy regarding annual Ethics training, and that ethics was included in the last quarter of the year as part of quarterly computer-generated training assignments. The DON and Administrator stated employees were responsible for completing training on time, and that delinquent staff should be held accountable, including being removed from the schedule until training was completed. A requested policy addressing annual employee training was not provided prior to exit.

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 thoroughly investigate an allegation that a resident’s money was stolen and failed to obtain relevant interviews and statements while the investigation was in progress. The resident was a 75-year-old female with severe bilateral glaucoma, severely impaired vision, and a BIMS score of 15, indicating cognitive intactness. Her care plan noted she was at risk for psychosocial well-being problems related to missing money, and she was angry that someone would take her money without permission. The resident reported that after a shower, she discovered a wallet with more than $200 missing and believed the CNA who assisted her had taken it. The facility investigation identified the CNA as the alleged perpetrator, suspended the CNA, and noted that the resident’s money was missing, but the investigation did not include interviews or statements from the night staff assigned to the resident during the relevant shift, and it did not include interviews or statements from other night staff. The investigation concluded the allegation was unconfirmed. During interviews, the Administrator stated he was responsible for thorough investigations and acknowledged that he did not obtain statements from all relevant staff, including the LVN who worked the shift and the CNA assigned to the resident’s care, and that he only asked a few staff if they knew anything. The resident, the CNA, the roommate, the LVN, another CNA, and the Social Worker provided accounts about the resident’s purse, wallet, and missing money, but the facility’s investigation did not document complete interviews from all involved persons as required by policy.

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 respiratory care for a resident with COPD, as evidenced by several deficiencies in oxygen administration. Observation revealed that the resident's humidifier was completely empty, and both the nasal cannula and humidifier had not been replaced according to the facility's stated weekly schedule. Documentation review showed that there were no orders or care plan interventions specifying the regular replacement of the nasal cannula or humidifier. Interviews with nursing staff and administration confirmed that the expectation was for these items to be changed weekly, but this was not consistently documented or carried out. The resident, who had severe cognitive impairment and required continuous oxygen therapy, was unaware of the status of his humidifier and could not recall when it was last changed. Staff interviews indicated that the responsibility for changing the equipment was shared among nurses, but there was a lack of clear documentation and adherence to the schedule. Additionally, the facility's policies did not include specific requirements for oxygen administration, and no additional policy could be provided upon request. These findings were based on direct observation, staff interviews, and review of the resident's medical records and facility policies.

Penalty

Inspection fine: $37,447

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 the medical record for one resident was complete and accurately documented, specifically regarding the parameters for holding insulin administration. The resident, who had diagnoses including Type II diabetes and dementia with severe cognitive impairment, had physician orders and MARs that inconsistently documented the blood glucose (BG) threshold for holding Novolog insulin. The physician order and MAR initially stated to hold insulin if BG was less than 200, but nursing staff and the nurse practitioner indicated that the correct threshold should have been 100. A nurse made a typographical error when entering the order into the electronic record, and this discrepancy was not identified or corrected in a timely manner. Despite the error in documentation, nursing staff reported that they consistently held the insulin if the resident's BG was less than 100, following standard nursing judgment rather than the incorrect written order. The facility's policy required that each resident's medical record contain an accurate and complete representation of the resident's care, but the error in the electronic record and MAR resulted in inaccurate documentation of the resident's insulin administration parameters.

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 an allegation of neglect involving a resident was reported to the State Survey Agency within the required 24-hour timeframe. A family member alleged neglect related to a change in the resident's condition, specifically regarding staff not suctioning the resident. The Director of Nursing was notified of the allegation by an LVN, and the Administrator attempted to submit the report in the TULIP system on the same day. However, there was no confirmation that the report was received, and no intake number was provided. Subsequent review of the facility's TULIP account showed no record of the report being submitted on the required dates. The resident involved was an older male with multiple complex medical conditions, including diabetes, metabolic encephalopathy, aphasia, hemiplegia, hemiparesis following a stroke, dysphagia, and a gastrostomy. Despite the facility's policy requiring follow-up with government agencies to confirm receipt of reports, the Administrator did not verify with the State Agency after the initial submission attempt. The report was ultimately resubmitted several days later, outside the required reporting window.

Penalty

Inspection fine: $45,812

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 thoroughly investigate and document allegations of abuse and neglect involving two residents. One resident alleged that a CNA made inappropriate sexual advances, while another resident reported that a CNA caused an injury during care. Despite these serious allegations, the facility did not conduct thorough investigations or report the incidents to the appropriate authorities in a timely manner. The first resident, who had a history of making false allegations, claimed that a CNA wanted to engage in inappropriate behavior. The facility's records did not show any investigation into this allegation, and the CNA continued to work at the facility until terminated for unrelated reasons. The second resident reported hearing a pop during care, which was later diagnosed as a chronic fracture. The facility did not suspend the CNA involved or report the incident as required, despite the resident's repeated claims of injury. Interviews with staff revealed a lack of consistent reporting and investigation procedures. Some staff members were unaware of the allegations, while others did not report them due to the residents' histories or perceived lack of intent. The facility's failure to act on these allegations placed residents at risk of further abuse and neglect, as the necessary protective measures were not implemented.

Removal Plan

• Resident #1 was discharged from the facility.
• An Allegation of Abuse was reported to HHSC for Resident #1.
• The Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
• The Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
• Resident #2 was interviewed regarding abuse and neglect with no reports and/or allegations of being abused and/or neglected.
• Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted.
• An allegation of abuse was reported to HHSC for Resident #2.
• The Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
• The Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
• The C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
• The Administrator and/or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified.
• Head to toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment with no concerns identified.
• The Administrator and/or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted.
• The DON/designee reviewed the resident progress notes to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified.
• The DON/Designee reviewed incident/accidents to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified.
• The Administrator and/or Designee reviewed resident grievances to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified.
• The Regional President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation.
• The Administrator/DON and/or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation.
• Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift.
• The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required.
• The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation.
• To monitor, the Administrator and/or designee and Director of Nursing/designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head to toe assessments were completed and provided.
• The Administrator will monitor to ensure new resident incidents are reviewed daily to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided.
• Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation.
• The facility has the Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/concerns will be reported to the Administrator/Abuse Coordinator immediately.

Penalty

Inspection fine: $45,812

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 report allegations of abuse involving two residents to the appropriate authorities within the required timeframe. One resident alleged that a CNA made inappropriate sexual advances, but the social worker did not report this to the administrator or the Health and Human Services Commission (HHSC). The Director of Nursing (DON) was also aware of the allegation but did not report it, as the resident had a history of making false allegations. The CNA in question continued to work at the facility until he was terminated for unrelated reasons. Another resident reported that a CNA caused a leg injury during care, but the allegation was not reported to HHSC. The resident stated that the injury was not intentional, and the CNA was not suspended or investigated at the time. The DON and the administrator were aware of the incident but did not report it, as they believed there was no intentional harm. The resident later received a diagnosis of a chronic femur fracture. Interviews with staff revealed a lack of consistent reporting and documentation of abuse allegations. The social worker admitted to not documenting or reporting the sexual abuse allegation due to the resident's history of making false claims. The DON and administrator acknowledged the importance of reporting but failed to act promptly. This lack of action placed residents at risk of further abuse and highlighted deficiencies in the facility's abuse reporting procedures.

Removal Plan

• Resident #1 was discharged from the facility.
• An Allegation of Abuse was reported to HHSC for Resident #1.
• The LBSW Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
• The Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
• Resident #2 was interviewed regarding abuse and neglect with no reports and/or allegations of being abused and/or neglected.
• Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted.
• An allegation of abuse was reported to HHSC for Resident #2.
• The Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
• The Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
• The C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
• The Administrator and/or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified.
• Head-to-toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment with no concerns identified.
• The Administrator and/or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted.
• The DON/designee reviewed the resident progress notes to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified.
• The DON/Designee reviewed incident/accidents to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified.
• The Administrator and/or Designee reviewed resident grievances to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified.
• The Regional President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation.
• The Administrator/DON and/or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Facility staff were reeducated the Abuse Coordinator and the Abuse Coordinator's role, as well as the Abuse Coordinator's contact information and where this information is located. Staff were reeducated on notifying the Director of Nursing, their immediate supervisor and/or regional staff if they are unable to reach the abuse coordinator.
• Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift.
• The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required.
• The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation.
• To monitor, the Administrator and/or designee and Director of Nursing/designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting, attended Monday-Friday. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head-to-toe assessments were completed and provided.
• The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided.
• Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation.
• The facility has the Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/concerns will be reported to the Administrator/Abuse Coordinator immediately.
• An AdHoc QAPI was conducted, attended by the Administrator, DON, Medical Director, and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 609 - Immediate reporting of allegations of abuse, neglect, and exploitation and misappropriation of resident property and develop the above Action Plan.

Penalty

Inspection fine: $45,812

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 consult with the residents' physicians when there was a need to alter treatment for two residents. Resident #3, an elderly female with hypothyroidism, did not receive her prescribed dose of Levothyroxine on a specific date in May 2024. The nursing notes lacked documentation indicating that the physician was notified about the missed dose. Similarly, Resident #4, an elderly female with multiple diagnoses including methemoglobinemia, hypertension, depression, and GERD, did not receive several prescribed medications on a specific date in September 2024. Again, there was no documentation in the nursing notes that the physician was informed about the missed doses. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed that the facility's staff did not follow the expected protocol of notifying the physician when medications were unavailable for administration. The DON expressed confusion as to why the staff did not notify the physician, acknowledging that the residents could experience a decline in health. The facility's policy on Notification of Changes, dated October 2022, mandates prompt consultation with the resident's physician and notification of the resident's representative when there is a change requiring notification. Despite the physician's statement that missing the doses would not cause adverse effects, the lack of notification was a clear deviation from the facility's policy.

Penalty

Inspection fine: $45,812

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 pharmaceutical services to meet the needs of two residents, resulting in missed initial doses of prescribed medications. Resident #3, a female with hypothyroidism, did not receive her prescribed Levothyroxine dose on May 21, 2024. The medication administration record (MAR) indicated the dose was not given, and attempts to contact the responsible LVN were unsuccessful. Resident #4, a female with multiple diagnoses including methemoglobinemia, hypertension, depression, and GERD, did not receive several prescribed medications on September 17, 2024. These medications included Carvedilol, Ferrous Sulfate, Hydralazine, Montelukast, Nifedipine, Protonix, and Sertraline. The MAR showed these doses were not administered, and the medication aide (MA) involved did not inform the nurse about the unavailability of the medications. Interviews with facility staff revealed that the facility had an emergency medication kit (EKit) available, which contained some of the required medications. The Director of Nursing (DON) and other staff members indicated that the EKit should have been used if the pharmacy had not delivered the medications. However, there was a lack of communication and awareness among staff regarding the use of the EKit and alternative pharmacy options, leading to the failure to administer the necessary medications to the residents.

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 prompt efforts were made to resolve grievances for a resident, as evidenced by the lack of thorough investigation or timely action regarding complaints made by the resident's family member. The resident, a female with multiple diagnoses including cerebral infarction, muscle wasting, hemiplegia, seizures, end-stage renal disease, heart failure, and stomach cancer, was dependent on assistance for personal care and was always incontinent of bladder and bowel. The resident's care plan highlighted the risk of impaired skin integrity due to incontinence, with interventions including timely incontinent care. A grievance was recorded on September 3rd, 2024, when a family member reported that the resident was not changed after a request was made to the nurse. The investigation revealed that staff were occupied with passing trays and assisting residents with dinner, delaying the resident's care. The resolution involved a plan to check the resident before meals to ensure timely care, which satisfied the family member. However, there was no grievance report available for August 2024, despite a family member's claim of making a grievance that month regarding the resident being left in feces. Interviews with facility staff, including the Administrator, Social Worker, Admissions Coordinator, and Director of Nursing, revealed a lack of awareness or recall of the August grievance. The facility's policy requires prompt efforts to resolve grievances, including acknowledgment, investigation, and communication of findings to the complainant. The absence of a documented grievance for August 2024 and the staff's lack of awareness indicate a failure to adhere to this policy, potentially leaving grievances unaddressed.

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 timely incontinent care to a resident, leading to a deficiency in maintaining personal hygiene. The resident, who had multiple medical conditions including cerebral infarction, muscle wasting, hemiplegia, and end-stage renal disease, was left in feces/diarrhea for approximately one hour. This incident occurred despite the resident's care plan indicating a risk of impaired skin integrity due to incontinence and the need for timely care. The Director of Nursing (DON) acknowledged that the resident should not have been left in such a condition and emphasized that residents should be checked and changed every two hours and as needed. Observations and interviews revealed that a family member informed an LVN about the resident's need for care, but the care was not provided promptly. A family member later found the resident still in a soiled state, and a picture was submitted to the state surveyor showing the extent of the issue. Staff interviews indicated a lack of recall or acknowledgment of the request for care, and the facility's perineal care policy was not adhered to, which mandates providing care to prevent infection and skin breakdown.

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 clinical records in accordance with accepted professional standards for a resident reviewed for accuracy of clinical records. The deficiency involved a lack of documentation by LVN A regarding an incident on 08/02/24, where the resident was observed biting her right hand. Despite being informed of this behavior by DR/OT B, LVN A did not document her assessment or any follow-up actions in the electronic health record (EHR). This omission was significant as the resident was later observed with injuries of unknown origin, including a bruise and scratches on her right hand and wrist, and edema around her right eye and forehead. The resident, who had a history of dementia, muscle wasting, contractures, and repeated falls, was dependent on others for all activities of daily living and mobility. On 08/05/24, the resident was found with a knot on her forehead, fluid pocket around her right eye, and bruising and scratches on her right wrist. Despite these findings, there was no documentation of any falls or incidents that could have caused these injuries. The lack of documentation and communication among staff members regarding the resident's condition and potential need for pain management contributed to the deficiency. Interviews with facility staff revealed inconsistencies in the reporting and documentation of the resident's condition. The DON and other staff members were not aware of the resident's self-injurious behavior or the subsequent injuries until they were observed by hospice staff. The facility's policy required timely and accurate documentation of assessments and observations, which was not adhered to in this case. This failure to document and communicate effectively placed the resident at risk of not receiving appropriate care and services to meet her needs.

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 residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. Resident #44, a female with severe cognitive impairment and dysphagia, was observed multiple times without her feeding tube connected and the feeding pump turned off, despite physician orders for continuous feeding with Jevity 1.5 at 65ml/hour. This indicates a failure to adhere to the prescribed feeding schedule, potentially compromising her nutritional intake and overall health. Resident #89, a male with a history of traumatic brain injury and chronic respiratory failure, also experienced issues with his enteral feeding. His feeding pump was observed to be in a state of alarm due to flow errors on multiple occasions, and there were instances where the pump was turned off without a clear physician order. Interviews with various LVNs revealed confusion and lack of clarity regarding the orders for turning off the enteral feeding, indicating a breakdown in communication and adherence to physician directives. The Director of Nursing (DON) was unable to provide a clear explanation for the feeding pump issues and could not locate a new dietary order from the Registered Dietitian. The facility also failed to provide a policy on enteral feeding before the survey exit. These deficiencies in managing enteral feeding for Residents #44 and #89 highlight significant lapses in ensuring proper nutrition and care for residents with feeding tubes, potentially leading to adverse health outcomes.

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 store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Observations revealed that sixteen stainless steel steam table pans were stacked wet on the pan storage rack, and a cook used a paper drying cloth to dry pans that were supposed to air dry. Additionally, a serving utensil containing dried food debris was found on the serving line. The dietary manager acknowledged these issues and provided documentation of staff training on the proper use of the 3-compartment sink and air drying of dishes. However, further observations showed that staff continued to improperly dry pans with paper towels, and a utensil with dried food debris was placed on the steam table for service before being noticed and removed for re-washing. The facility's policy and FDA Food Code require that equipment and utensils be air-dried to prevent re-contamination, which was not consistently followed in this case. In the memory care unit, untrained staff were observed making peanut butter and jelly sandwiches in a non-designated food preparation area without proper equipment or sanitizing supplies. The staff member did not wear a hair net or apron, used a shampoo and body wash solution to wash hands, and did not sanitize the countertop before preparing the sandwiches. The bread used for the sandwiches was not labeled with an initial open use date. Interviews with staff revealed that the kitchen did not consistently provide snacks for the memory unit, leading to untrained staff making sandwiches for residents. The dietary manager admitted that the decision to have the memory unit staff make their own snacks was due to the high wastage of pre-made sandwiches and acknowledged that the area used for sandwich preparation was not adequately equipped or sanitized. The facility's failure to ensure proper food storage, preparation, and distribution practices, as well as the lack of training and certification for staff preparing food in the memory unit, could place residents at risk of foodborne illness. The dietary manager and other staff members were aware of the issues but did not take adequate steps to address them, resulting in unsanitary conditions and potential health risks for residents consuming the food prepared under these conditions.

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 prevention and control program, leading to potential cross-contamination and the spread of infection among residents. During medication administration, an LVN did not use appropriate hand hygiene practices. The LVN was observed administering medications to three residents without sanitizing her hands before and after each task, despite touching various items and residents. This failure was acknowledged by the LVN and the DON, who confirmed that proper hand hygiene is crucial for infection control. Additionally, the facility did not ensure proper handling of enteral feeding equipment. An LVN used a bottle of formula and tubing that had been left open and uncovered for approximately 24 hours. The LVN admitted to not obtaining a new bottle of formula or new tubing, which should have been done to prevent contamination. The DON and a Nurse Consultant confirmed that the facility lacked a specific policy for enteral feedings, although the manufacturer's instructions indicated that an opened bottle of formula could hang for up to 48 hours. The deficiencies involved four residents with serious medical conditions, including infections and surgical interventions. The lack of proper hand hygiene and the improper handling of enteral feeding equipment could lead to the transmission of infections, posing significant risks to the residents' health and safety.

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 baseline care plan within 48 hours of admission for a resident, which included the necessary instructions to provide effective and person-centered care. The resident, an elderly male, was admitted with multiple diagnoses including pneumonia, Covid-19, dehydration, Parkinson's Disease, dysphagia, generalized weakness, and vitamin deficiency. Despite these complex medical conditions, the baseline care plan only addressed the resident's cardiopulmonary resuscitation status and dependency on staff for socialization and activity needs, neglecting other critical aspects of his care such as weight monitoring, fall risk, ambulation needs, and therapy requirements. The Director of Nursing (DON) acknowledged that the baseline care plan was incomplete and confirmed that it was her responsibility to ensure its completion. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission, including initial goals based on admission orders and physician directives. However, the care plan for this resident did not address his admitting diagnoses, physician orders, or risk assessments for falls, pressure ulcers, and pain, thereby placing the resident at risk of receiving inadequate care and services.

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 #360 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not obtain the resident's weight on admission as ordered by the physician. The resident, a male with a history of dehydration, dysphagia, generalized weakness, and vitamin deficiency, was admitted with additional diagnoses of Covid-19, pneumonia, and dehydration. Despite physician orders to weigh the resident on admission and weekly thereafter, the initial weight was not documented in the computerized medical record, nor was it communicated to the Registered Dietician. The resident's care plan also did not address weight concerns or dietary recommendations, despite the resident's frail and malnourished condition upon admission. The Restorative Aide, responsible for weighing residents, indicated that the weight was taken five days after admission but was not entered into the computer system due to being frequently pulled to assist on the floor when the facility was short-staffed. This delay and lack of documentation resulted in the Registered Dietician not having the necessary information to evaluate the resident's dietary needs. During interviews, the DON acknowledged the failure to comply with the physician's order for weighing the resident on admission and recognized the potential impact of this failure on the resident's care. The discrepancy in weights taken on different dates was attributed to the use of different scales (wheelchair vs. bed scales). The facility's policy on weight monitoring emphasized the importance of obtaining and recording weights upon admission to assess nutritional risk, but this policy was not followed in the case of Resident #360. The failure to obtain and document the resident's weight as ordered could lead to delays or absence of necessary care and services to prevent weight loss.

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 a resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease. Specifically, the facility did not place hand rolls and/or positioning devices in the resident's right hand as ordered by the physician. The resident, a [AGE] year-old female with diagnoses including contracture of the right hand, muscle wasting, and unspecified dementia, was observed multiple times without the required hand roll in place. This was despite physician orders indicating the need for a hand roll every shift and the care plan addressing the contractures of the right hand. The treatment administration record also indicated that the resident should have had a hand roll in place, but observations on several occasions showed otherwise. Interviews with staff, including the ADON and a CNA, revealed that it was everyone's responsibility to ensure the hand rolls were in place, yet the CNA admitted to not placing any hand rolls for the resident. Additionally, the facility did not provide a policy on Range of Motion and placement of handrolls/splints when requested. This lack of adherence to the care plan and physician orders could place the resident at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

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 post Nursing Staffing Data information daily as required for three of the four days reviewed. Specifically, the facility did not post the total number of hours worked for licensed nurses and certified nurse aides or the daily census for May 17th, 18th, and 19th of 2024. During an observation on May 20th, the staffing sheet posted was dated May 16th in the morning and May 20th in the afternoon. Interviews revealed that the staffing coordinator, who worked Monday through Friday, did not have the staffing sheets for the missing dates and was unaware of who was responsible for posting them on weekends. The Administrator confirmed that the MOD was responsible for posting the sheets on weekends, but the BOM, who served as the MOD on weekends, was not informed of this responsibility and thus did not post the sheets. Record review of the facility's staffing sheets for May 2024 indicated there were no documented staffing sheets on May 17th, 18th, and 19th. The facility's Nurse Staffing Posting Information policy, dated October 24, 2022, stated that nurse staffing information should be made readily available in a readable format to residents and visitors at any given time and that the Nurse Staffing Sheet should be posted daily at the beginning of each shift. The Administrator was unaware that the staffing sheets were not being posted on weekends and expected the staffing to be posted daily to assure residents and family members of adequate staffing.