Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Branch Transitional Care Center during CMS and state inspections, most recent first.
The facility failed to follow food safety standards, including not discarding expired food and improper storage practices. Additionally, a sewage backup in the kitchen was not reported to the health department. The Dietary Food Service Manager and Administrator acknowledged these oversights, and the health inspector identified necessary repairs before reopening the kitchen.
A facility failed to provide proper care for a resident with a suprapubic Foley catheter, resulting in a deficiency related to urinary tract infection prevention. A CNA left the catheter on the bed during care, contrary to protocols requiring the urine bag to be below the bladder. The resident had a history of UTIs and was on antibiotics. The CNA and unit manager were unaware of proper procedures, and no training records were found.
A resident with severe cognitive impairment was found with bed rails installed without a physician's order or care planning, contrary to the facility's restraint-free policy. Staff interviews revealed a lack of awareness and adherence to the policy, as the resident's medical history and condition did not indicate the need for bed rails.
The facility experienced a failure in maintaining emergency power during a prolonged outage due to inadequate monitoring of the generator's fuel supply. The generator ran out of fuel, leaving the facility without power for three hours. This affected residents relying on life support systems, such as those using air mattresses and oxygen concentrators. The increased load from additional portable a/c units contributed to the faster depletion of fuel.
The facility failed to maintain proper food temperatures on the breakfast tray line serving cart and did not store food in designated areas. Observations revealed that food temperatures were within the 'danger zone,' and several cases of dry goods were stored on the floor. The Dietary Food Service Manager acknowledged these issues.
The facility failed to ensure that two residents were dressed in their own clothes, compromising their dignity and respect. Both residents were found wearing clothes with another resident's name on them, and staff interviews confirmed this was inappropriate. The facility's policy on resident rights was not adhered to, highlighting a deficiency in maintaining residents' dignity.
The facility failed to develop and implement a baseline care plan for a resident prescribed Haloperidol, leading to the resident being unresponsive and shaking. The MDS coordinator and Administrator confirmed that the baseline care plan should have been completed by the nurse who received the medication order.
A facility failed to follow a physician's orders for administering a nutritional supplement to a resident with multiple medical conditions, including Huntington's disease and dysphagia. The medication aide administered only 100 ml of Plus Boost instead of the prescribed 237 ml carton with meals, leading to a deficiency in care. Interviews with staff confirmed the failure to adhere to the care plan and physician's orders.
The facility failed to ensure that two residents received necessary personal hygiene and grooming services. One resident with Alzheimer's and dementia had inconsistent shower documentation and dry, flaky skin, while another resident with parkinsonism and heart failure was found with wet bed linens and an incontinent brief on the floor. Staff interviews revealed lapses in regular checks and adherence to care protocols, compromising residents' dignity and comfort.
The facility failed to ensure proper incontinent care and hand hygiene for two residents, leading to potential risks of infection. One resident was not cleaned properly during incontinent care, and another had improper Foley catheter care with cross-contamination and incorrect leg bag positioning.
The facility failed to accurately dispense and administer medications for two residents. One resident was given Omeprazole at the wrong time, and another was given the incorrect dosage of Ginkgo Biloba. These errors were due to a lack of awareness and a transcription error.
The facility failed to ensure that the attending physician reviewed and provided a clinical rationale for the consulting pharmacist's medication regimen review recommendations for a resident with multiple diagnoses. The physician declined the recommendations without providing details, and interviews with the DON and ADM confirmed awareness of the requirement and potential risks.
The facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Despite the care plan's requirements, records from January to April lacked documentation of behavior monitoring for Haloperidol, side effect monitoring for Seroquel, and behaviors justifying Paroxetine HCL administration. Interviews with staff revealed inconsistencies in monitoring practices, and observations showed the resident unresponsive and shaking.
The facility failed to maintain a medication error rate below 5%, with errors involving two residents and one staff member. One resident received the wrong dosage of Ginkgo Biloba, and another received Omeprazole at the incorrect time. Both errors were confirmed through observations and interviews.
The facility failed to ensure proper disposal of garbage by not securing the lids and doors of a commercial-size dumpster, which was found 3/4 full with its door open. The Food Service Manager confirmed that the dumpster doors must always be closed to prevent pests from entering the facility. Staff from dietary, nursing, and housekeeping are responsible for ensuring the dumpster doors are kept closed.
The facility failed to maintain an infection prevention and control program, leading to improper hand hygiene and cleaning procedures for two residents. One resident was not cleaned thoroughly during incontinent care, and another had improper Foley catheter care, including cross-contamination and urine backflow. Staff interviews confirmed these deficiencies.
A resident with a history of UTIs and other health issues was found with a soiled brief that had not been changed since the night shift, despite requesting assistance. CNA A, who was understaffed, failed to thoroughly clean the resident, leaving feces in the vaginal area and redness on the buttocks. The facility's policy on perineal care was not followed, and discrepancies in care frequency expectations were noted among staff.
A resident with multiple health conditions was at risk due to improper infection control practices by two CNAs. CNA A failed to change gloves and sanitize hands during incontinent care, while CNA B used an unsanitized bedside table from another room and placed soiled linens on the floor. CNA B missed mandatory infection control training, contributing to the deficiency.
Food Safety and Reporting Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed in the kitchen. Foods were not dated or discarded according to the facility's policy, which requires potentially hazardous leftovers to be discarded within 72 hours. Specifically, a plastic bag of deli ham was found in the refrigerator with a use-by date that had already passed, and sandwiches were stored without proper dating. Additionally, food storage racks were not maintained at the required height of 6 inches off the floor, which is necessary to prevent cross-contamination. Furthermore, the facility did not report a sewage backup in the kitchen to the local health department, as required. The Dietary Food Service Manager acknowledged the oversight and the importance of maintaining air gaps to prevent contaminated water backflow. The Administrator admitted to not understanding the necessity of air gaps and expressed concern about involving the health inspector, fearing the kitchen would be closed. Despite this, the health inspector was eventually contacted and identified a list of necessary repairs and cleaning tasks before the kitchen could be reopened.
Inadequate Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic Foley catheter, leading to a deficiency in preventing urinary tract infections. During an observation, a CNA left the resident's Foley catheter on the bed with urine in the bag during incontinent care, which is against proper catheter care protocols. The urine was noted to be cloudy, indicating a potential infection risk. The CNA stated that she placed the urine bag on the bed to prevent the catheter from kinking, and the unit manager incorrectly confirmed this practice as acceptable. The resident involved had a history of urinary tract infections and was receiving antibiotics for various infections over several months. The resident's care plan required that the catheter tubing be secured to the leg and the urine bag be kept below the bladder to prevent infections. However, the facility's records showed no evidence of training for the CNA on proper catheter care, and the Director of Nursing confirmed that the catheter should not be placed on the bed. The facility's policy on Foley catheter care was not provided during the survey, indicating a lack of adherence to established protocols.
Failure to Assess and Plan for Bed Rail Use
Penalty
Summary
The facility failed to attempt appropriate alternatives before installing bed rails for a resident, who was observed with side rails on both sides of the bed at the head. The resident, who had a severely impaired cognition with a BIMS score of 6, was not care planned for bed rails, and there was no physician's order for their use. The resident's medical history included cerebral infarction, aphasia, hemiplegia, hemiparesis, hypertension, type two diabetes mellitus, hyperlipidemia, and heart disease. Despite the facility's policy of being restraint-free, the resident was found with bed rails, which were not indicated as per the evaluation done by the Unit Manager. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy on bed rails. The resident's nurse and the Unit Nurse Manager both acknowledged that bed rails were considered a restraint and should not be used without proper assessment and care planning. The Director of Nursing stated that bed rails could be used if an assessment was done and the resident was care planned for them, but this was not the case for the resident in question. The facility's policy on bed safety required an assessment, consent, and a physician's order for side rail use, none of which were documented for the resident.
Emergency Power Failure During Outage
Penalty
Summary
The facility failed to ensure that an emergency electrical power system with an emergency generator was adequately maintained to supply power for life support systems during a power outage. The generator ran out of fuel on the morning of 5/20/24, leaving the facility without emergency power for approximately three hours. This occurred after a natural disaster caused a power outage on 5/16/24, and the generator had been running continuously since then. The facility staff did not monitor the generator's fuel burn rate effectively, leading to the depletion of fuel earlier than anticipated. The Maintenance Director and Administrator were aware of the generator's fuel levels but underestimated the impact of additional portable air conditioning units on fuel consumption. The generator was filled to capacity on 5/16/24 and again on 5/17/24 with an additional 300 gallons. However, the increased load from the portable a/c units, purchased to keep residents cool, accelerated fuel usage. The Maintenance Director failed to secure additional fuel in time and did not consider conserving power, resulting in the generator running out of fuel by 6:30 AM on 5/20/24. During the power outage, residents who relied on life support systems were affected. Residents using air mattresses experienced deflation, and those on oxygen concentrators had to be switched to portable oxygen tanks. The Director of Nursing expressed concerns about the potential worsening of pressure ulcers due to the lack of power. The facility's policy on extended power outages highlighted the critical nature of maintaining power for residents with specific medical needs, but the failure to monitor and manage the generator's fuel supply led to a significant lapse in emergency power provision.
Failure to Maintain Proper Food Storage and Temperature
Penalty
Summary
The facility failed to maintain proper temperature for food in the breakfast tray line serving cart and did not ensure that food was always stored in designated areas. Observations and temperature recordings on the breakfast tray line serving cart revealed that the food temperatures were below the recommended levels. Specifically, the temperatures of turkey sausage, chopped sausage, pureed sausage, pureed scrambled eggs, vanilla pudding, yogurt, and milk were all within the 'danger zone' of 41 to 135 degrees Fahrenheit, which can promote bacterial growth. The Dietary Food Service Manager acknowledged the issue and stated that maintaining proper food temperature during serving time is her responsibility. Additionally, the facility failed to store several cases of food off the floor, which were delivered the day before. An observation of the facility storeroom revealed several cases of dry goods stored on the floor. The Dietary Food Service Manager admitted that the food supply order was delivered the previous afternoon, and she did not have the staff and time to put the delivered items in the designated area. The facility's policies and procedures for Safe Food Handling and Food Safety in receiving and storage were not followed, as they require hot foods to be maintained at 140 degrees Fahrenheit or higher, cold foods at 40 degrees Fahrenheit or below, and all foods to be stored at least 6 inches off the floor.
Failure to Maintain Resident Dignity by Dressing in Own Clothes
Penalty
Summary
The facility failed to ensure that two residents, Resident #54 and Resident #148, were dressed in their own clothes, which compromised their dignity and respect. Resident #54, who has Alzheimer's disease and dementia, was found wearing clothes with another resident's name on them on multiple occasions. This was confirmed by the resident's family member, who reported the issue to the nurse. During an observation, Resident #54 was seen wearing off-white pants and multicolored socks with another resident's name. Interviews with CNA R, the Unit Manager, and the ADON confirmed that dressing residents in another's clothes was inappropriate and a dignity issue. The staff acknowledged that the nurse and aides should monitor and ensure residents are dressed in their own clothes during rounds and care provision. Similarly, Resident #148, who has frontotemporal neurocognitive disorder and impaired cognition, was observed wearing a brown dress with another resident's name on it. CNA W, who dressed Resident #148, found the dress in the resident's closet and assumed it belonged to her. The Unit Manager and LVN S confirmed that it was inappropriate for Resident #148 to be dressed in another resident's clothes and emphasized the importance of maintaining the resident's dignity. The DON also acknowledged that residents should wear their own clothes and that aides and nurses should monitor this during rounds. The facility's policy on resident rights, which emphasizes treating all residents with kindness, respect, and dignity, was not adhered to in these instances. The failure to ensure that residents were dressed in their own clothes was identified as a deficiency, highlighting the need for better monitoring and adherence to policies to maintain residents' dignity and respect.
Failure to Implement Baseline Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #135, who was prescribed Haloperidol, a first-generation typical antipsychotic, on 03/01/24. The resident, a 73-year-old with multiple diagnoses including schizophrenia, paranoid personality disorder, and anxiety disorders, was readmitted to the facility on an unspecified date. Despite the physician's order for Haloperidol, the baseline care plan did not include any interventions for the use of this medication. This omission was noted during a review of the resident's care plan dated 03/10/2023, which only mentioned monitoring for potential side effects and adverse reactions without specific instructions for Haloperidol use. Observations made on 4/16/24 and throughout the survey on 4/19/24 showed Resident #135 lying in bed, unresponsive, and shaking. Interviews with the MDS coordinator and the Administrator revealed that the nurse who received the new medication order should have completed the baseline care plan. The Director of Nursing (DON) acknowledged that the failure to complete the baseline care plan could result in staff not knowing how to best care for the resident. The facility's policy regarding baseline care plans was requested but not provided before the survey exit.
Failure to Follow Physician's Orders for Nutritional Supplement
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident reviewed for professional standards. Specifically, the nursing staff did not follow the physician's orders for administering a nutritional supplement. The resident, a female with multiple medical diagnoses including Huntington's disease, muscle wasting, cognitive communication deficit, and dysphagia, was prescribed a house supplement liquid to be given orally with meals three times a day. However, observations and interviews revealed that the medication aide was administering only 100 ml of Plus Boost instead of the prescribed 237 ml carton with meals. This discrepancy was not in line with the physician's orders documented in the Medical Administration Record (MAR) and the care plan, which aimed to address the resident's nutritional deficiency and weight loss issues. The deficiency was further highlighted during interviews with the medication aide and the Director of Nursing (DON). The medication aide admitted to not following the physician's orders and expressed regret, acknowledging the importance of the supplement in helping the resident gain weight. The DON confirmed that the nurses should have been following the physician's orders and recognized that not doing so could potentially affect the resident's health. The administrator also emphasized the expectation for accurate documentation and adherence to physician's orders, noting that signing off on unadministered treatments constituted falsification of records. No policy and procedure regarding following physician orders was provided by the administrator prior to the exit from the facility.
Failure to Provide Adequate Personal Hygiene and Grooming Services
Penalty
Summary
The facility failed to ensure that two residents, who were unable to carry out activities of daily living (ADLs), received the necessary services to maintain their personal hygiene and grooming. Resident #54, a female with Alzheimer's disease, dementia, and hypertensive heart disease, required maximum assistance from staff for grooming and personal hygiene. Despite this, the facility's records showed inconsistencies in providing showers and bed baths, with several instances of missing documentation. Observations revealed that Resident #54 had dry, flaky skin, indicating a lack of proper hygiene care. Interviews with staff confirmed that the resident's showers were not consistently documented or provided, and there was a lack of communication and monitoring among the staff regarding the resident's hygiene needs. Resident #117, a female with parkinsonism, heart failure, and dementia, was also dependent on staff for personal hygiene and toileting. The resident was found sitting in her wheelchair with wet bed linens and an incontinent brief on the floor, indicating that she had not been checked on or assisted by the staff. Interviews with the staff revealed that the aides did not make regular rounds to check on the resident, and there was a lack of adherence to the facility's policy of checking on residents every two hours. The staff admitted to not following proper procedures for ensuring the resident's bed was clean and dry, which compromised the resident's dignity and comfort. The facility's failure to provide adequate personal hygiene and grooming services to these residents resulted in discomfort and potential health risks. The staff's lack of proper documentation, communication, and adherence to care protocols contributed to the deficiencies observed. The facility's management acknowledged the issues but did not provide a clear explanation for the lapses in care, highlighting a need for improved oversight and accountability in ensuring residents' personal care needs are met.
Inadequate Incontinent and Foley Catheter Care
Penalty
Summary
The facility failed to ensure proper incontinent care and hand hygiene for two residents, leading to potential risks of infection. For Resident #148, a [AGE] year-old female with diagnoses including frontotemporal neurocognitive disorder, UTI, and hypertensive heart disease, CNA H did not wash or sanitize her hands before donning gloves and failed to clean the resident's pubic area and buttocks properly. This improper cleaning was observed during an incontinent care session, where bowel movements were still present on the resident's buttocks, and the labia was not separated for thorough cleaning. Interviews with CNA H, CNA W, the Unit Manager, and the DON confirmed these observations and highlighted the risk of infection and skin breakdown due to improper cleaning and cross-contamination from using the same gloves to access clean wipes. For Resident #181, a [AGE] year-old male with diagnoses including dementia, obstructive and reflux uropathy, benign prostatic hyperplasia, and UTI, CNA J failed to follow proper hand hygiene and Foley catheter care procedures. During an observation, CNA J used the same gloves throughout the Foley care process, causing cross-contamination by using dirty gloves to pull wipes from the container. Additionally, Resident #181's Foley catheter leg bag was observed to be at the same level as his bladder while he was lying in bed, causing urine to flow backward toward the bladder. Interviews with CNA J, the Unit Manager, RN A, and the DON confirmed these observations and acknowledged the risk of infection due to improper Foley care and cross-contamination. The facility's policies on peri care and catheter care were not followed, as evidenced by the improper cleaning techniques and failure to maintain the catheter bag below the bladder level. The deficiencies in hand hygiene and proper care procedures for both residents were confirmed through multiple interviews and observations, indicating a lack of adherence to infection control protocols and proper care standards.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to accurately dispense and administer medications for two residents. Resident #176, a male with multiple medical conditions including dementia and gastro-esophageal reflux disease, was prescribed Omeprazole 40 mg to be administered daily at 6:30 AM. However, it was observed that the medication was administered at 8:45 AM instead. The medication aide admitted to not realizing the correct administration time, despite having received in-service training on medication administration. Resident #48, a female with conditions such as schizoaffective disorder and hypoglycemia, was prescribed Ginkgo Biloba 3000 mg to be taken three times a day. However, it was observed that the resident was administered Ginkgo Biloba 120 mg instead. The medication aide was unaware that Ginkgo Biloba comes in a 3000 mg dosage and was using the only available bottle in the medication cart. The Director of Nursing confirmed a transcription error upon review of the medication administration record and physician's orders.
Failure to Document Clinical Rationale for Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and provided a clinical rationale for the consulting pharmacist's medication regimen review recommendations for a resident. Specifically, the physician did not document a clinical rationale for declining the pharmacist's recommendations for potential dose reductions of Seroquel, Haloperidol, and Paroxetine. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, schizophrenia, and anxiety disorders, and required assistance with activities of daily living. The pharmacist's recommendations were not adequately addressed, as the physician simply checked the decline box without providing any details in the description section. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that both were aware of the requirement for psychotropic medication reviews and the necessity for the physician to provide a clinical rationale when declining recommendations. The DON stated that she was primarily responsible for following up on the pharmacy consultant's recommendations and acknowledged the risk of not having a clinical rationale documented. The ADM also recognized the potential risk of inadequate medication review by a medical doctor if the physician did not provide a precise clinical rationale. A request for the facility's medication administration policy was made but not provided before the exit interview.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that Resident #135's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Specifically, the facility did not document behavior monitoring for Haloperidol, side effect monitoring for Seroquel, or behaviors justifying the administration of Paroxetine HCL. This lack of documentation was observed in the Medication Administration Records (MAR) and nurse's notes over several months, indicating a systemic issue in monitoring and documenting the resident's response to these medications. Resident #135, a 73-year-old with a history of schizophrenia, paranoid personality disorder, and anxiety disorders, among other conditions, was prescribed multiple psychotropic medications. Despite the care plan indicating the need for behavior and side effect monitoring, the records from January to April did not reflect any such documentation. Observations during the survey period showed the resident lying in bed, unresponsive, and shaking, which raised concerns about the effectiveness and necessity of the psychotropic medications being administered. Interviews with the Unit Manager, Director of Nursing (DON), and MDS Coordinator revealed inconsistencies in behavior monitoring practices. The Unit Manager acknowledged the lack of behavior monitoring documentation, and the DON confirmed that such documentation was essential for tracking the effectiveness and adverse reactions of psychotropic medications. The MDS Coordinator mentioned an incident of verbal aggression by the resident that was not documented or reported. The Administrator also emphasized the importance of behavior and side effect monitoring but admitted that chart audits were not consistently performed to ensure compliance.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was not 5% or greater, resulting in a medication error rate of 5%. This involved two residents and one staff member. MA A failed to administer Resident #48's Ginkgo Biloba 3000 mg as ordered by the physician on 04/16/24, instead administering Ginkgo Biloba 120 mg. MA A was not aware that Ginkgo Biloba comes in 3000 mg, and this was identified as a transcription error. Resident #48, a [AGE] year-old female with diagnoses including schizoaffective disorder and anxiety disorder, was moderately cognitively impaired with a BIMS score of 09. The error was observed during medication administration rounds and confirmed through interviews and record reviews. MA F failed to administer Resident #176's Omeprazole 40 mg at the correct time on 04/17/24, administering it at 8:45 AM instead of the prescribed 6:30 AM. Resident #176, a [AGE] year-old male with diagnoses including dementia and type 2 diabetes mellitus, was also moderately cognitively impaired with a BIMS score of 09. The error was observed during medication administration rounds and confirmed through interviews and record reviews. Both errors were acknowledged by the staff involved, who admitted to not following the physician's orders correctly.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the proper disposal of garbage and refuse, specifically by not securing the lids and doors of a commercial-size dumpster located behind the dietary department. During an observation, the dumpster was found to be 3/4 full with its door open. The Food Service Manager confirmed that the dumpster doors must always be closed to prevent vermin, pests, and insects from entering the facility. It was noted that staff from dietary, nursing, and housekeeping departments are responsible for ensuring the dumpster doors are kept closed. A review of the facility's Nutrition Services Policies and Procedures on waste disposal revealed that waste containers and dumpsters should have lids covering them when not in use and should not be overflowing.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to deficiencies in the care of two residents. For Resident #148, the facility did not ensure proper hand hygiene and cleaning procedures during incontinent care. CNA H did not wash or sanitize her hands before donning gloves and failed to clean the resident's pubic area and buttocks thoroughly, leaving bowel movements on the skin. This was confirmed through observations and interviews with the CNA, unit manager, and other staff members, who acknowledged the improper procedures and the potential for cross-contamination and infection. For Resident #181, the facility did not ensure proper hand hygiene and Foley catheter care. CNA J used the same gloves throughout the entire Foley care process, including handling wipes and the resident's leg bag, which led to cross-contamination. Additionally, the resident's Foley leg bag was observed to be at the same level as the bladder, causing urine to flow back towards the bladder. Interviews with the CNA, unit manager, and other staff members confirmed the improper procedures and acknowledged the risk of infection due to the backflow of urine and cross-contamination. Both residents had significant medical histories, including neurocognitive disorders, urinary tract infections, and other conditions that made them vulnerable to infections. The facility's failure to follow proper infection control practices and hand hygiene protocols directly contributed to the deficiencies observed in the care of these residents.
Inadequate Incontinent Care Leads to Risk of UTIs
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bowel and bladder, leading to a risk of urinary tract infections (UTIs) and decreased quality of life. The resident, a 56-year-old female with a history of dementia, anxiety, type 2 diabetes, and recurrent UTIs, was found with a soiled brief that had not been changed since the night shift. Despite the resident's request for assistance, CNA A did not return to change the brief, resulting in the resident's distress and tears. Observations revealed that CNA A, along with CNA B, eventually attended to the resident but failed to thoroughly clean the resident's vaginal area, leaving feces present and redness on the buttocks. This inadequate care was compounded by staffing issues, as one CNA was absent, leaving only two CNAs to care for 40 residents. CNA A acknowledged the risk of infections and skin breakdown when briefs are not changed timely. Interviews with staff, including the Unit Manager and DON, highlighted discrepancies in the expected frequency of incontinent care, with the Unit Manager stating care should occur every hour and the DON stating every two hours. The facility's policy on perineal care, which emphasizes cleanliness and infection prevention, was not adhered to, contributing to the deficiency.
Infection Control Deficiency Due to Improper Practices by CNAs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the care of a resident. CNA A did not change gloves or sanitize her hands before placing a clean fitted sheet on the resident's mattress after providing incontinent care. This lapse in protocol occurred despite the resident's brief being heavily soiled with urine and feces. CNA A admitted to not changing gloves due to nervousness during the care process. CNA B contributed to the deficiency by taking a bedside table from another resident's room without sanitizing it before use in the care of the resident. Additionally, CNA B placed a bag containing soiled linens on the floor, which is against infection control practices. CNA B was unaware that these actions were incorrect and had not attended the recent mandatory infection control training due to work commitments. The resident involved was a 56-year-old female with multiple diagnoses, including dementia, anxiety, type 2 diabetes, and a history of urinary tract infections. The resident was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. The facility's infection control nurse confirmed that staff should not share equipment between residents or place soiled linen bags on the floor, and that all staff were required to attend infection control training at hire and annually.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Avir At Arden Wood | 0.9 mi | ★★★★★ | 18 | 0 |
| Memorial City Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 10 | 0 |
| The Vosswood Nursing Center | 2.8 mi | ★★★★★ | 0 | 0 |
| The Hallmark | 4 mi | ★★★★★ | 0 | 0 |
| The Buckingham | 4.2 mi | ★★★★★ | 8 | 0 |
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