West Houston Rehabilitation And Healthcare 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 that residents had a safe, clean, comfortable, and homelike environment when privacy curtains in multiple resident rooms were observed with stains and buildup. The deficiency involved 6 of 10 residents reviewed for resident rights, including Residents #1, #2, #3, #5, #9, and #10. The report states that the curtains were not free of stains and other buildup, and that this condition could place residents at risk of injuries, cross-contamination, avoidable infections, and a decrease in quality of life. Resident #2 was a male with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dementia, and cognitive communication deficit. His Quarterly MDS showed a BIMS score of 03 out of 15 and total dependence on staff for all ADLs, including eating, oral and personal hygiene, dressing, showering, and toileting. Resident #9 was a male with diagnoses including injury of nerve root of cervical spine, functional quadriplegia, polyneuropathy, and vascular dementia. His Quarterly MDS showed a BIMS score of 15 out of 15 and total dependence on staff for all ADLs. During observation and interview, Resident #9's curtain had black stains near the netting at the top and a one-inch brown stain in the middle, and Resident #2's curtain had gray markings along the length. Resident #9 said the facility last washed the curtains seven months ago during the holidays and said he had told aides about the soiled curtains. Resident #10 was a female with diagnoses including dementia, generalized anxiety disorder, history of falling, and abnormalities of gait and mobility. Her Quarterly MDS showed a BIMS score of 09 out of 15, with moderate cognitive impairment, and she required moderate to maximal assistance with several ADLs. During observation, her middle privacy curtain had brown spots along the right side, and later the same curtain still had reddish-brown spots. Resident #10 said she did not see anyone come to change and clean the curtains and stated that staff should clean them when there were stains. Resident #3 was a male with diagnoses including dementia, chronic kidney disease, and muscle weakness, with a BIMS score of 03 out of 15 and moderate assistance needed for all ADLs. His curtain had reddish spots along the top facing his side, and the HKS later observed brown stains at the bottom of the curtain facing his side and said it needed to be taken down for washing. Resident #1 was a female with diagnoses including dementia, chronic kidney disease, major depressive disorder, and dysarthria/anarthria. Her Quarterly MDS showed a BIMS score of 05 out of 15, and she required maximal assistance with dressing and showering and moderate assistance with oral and personal hygiene. Her privacy curtain had a black stain at the end and several dark spots along the curtain, and she said the curtains did not get cleaned often and that she would like them cleaned. The HKS inspected the curtains in Residents #1 and #8's room and found stains along the sides and bottom, stating they needed to be removed for washing. Staff interviews reflected that housekeeping and maintenance were responsible for curtain cleanliness, but the curtains remained soiled at the time of observation.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide oxygen therapy with properly maintained humidifier bottles for residents requiring respiratory care, as required by professional standards, the care plans, and facility policy. For Resident #27, who had diagnoses including hypertension, atrial fibrillation, congestive heart failure, COPD, and chronic respiratory heart failure with hypoxia, the care plan directed use of oxygen via nasal cannula with monitoring of oxygen saturation and application of oxygen as ordered. During an observation, the resident was in bed receiving oxygen at 4 L/min via concentrator, and the attached humidifier bottle, dated several days earlier, was found to be empty. In interviews, Resident #27 reported that staff normally did not check the humidifier water bottle and that she frequently had to notify them when it was empty, with staff taking a long time to change it. She stated she felt okay but noted her nostrils were a little dry. The assigned LVN stated she had checked the water at the beginning of her shift and saw a small amount of water but had not checked it again and acknowledged the bottle should be changed when empty and that the humidifier should be checked at the beginning of each shift. She stated that lack of water in the humidifier could cause dryness and nosebleeds and admitted that checking the humidifier had been overlooked. For Resident #48, who had diagnoses including hypertension, atrial fibrillation, COPD, and chronic respiratory heart failure with hypoxia, the MDS and care plan documented that she received respiratory treatments and continuous oxygen therapy at 2–5 L/min, with physician orders specifying continuous oxygen via nasal cannula and monitoring of oxygen saturation each shift. Observation showed the resident in bed with oxygen infusing at 4.5 L/min and the oxygen tank humidifier bottle, dated several days earlier, completely empty. The resident stated the humidifier water was supposed to be changed weekly but that staff usually did not change it as they should and sometimes took a long time after she notified them. The assigned LVN reported she had checked the bottle earlier and found the water low but had not rechecked it and acknowledged that an empty bottle should be changed and that lack of water could cause shortness of breath, sinus problems, and mental confusion. The DON stated that nurses were responsible for checking humidifiers during rounds and replacing bottles when empty, and the facility’s oxygen policy required changing humidifier bottles when empty and using humidification for nasal cannula flow rates greater than 4 L/min.

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 a resident's call light was within reach, which is a necessary accommodation for the resident's needs. The resident, a female with a history of cerebral infarction, hypertension, and diabetes mellitus, was found to have her call light on the floor, out of reach. This resident was moderately cognitively impaired and dependent on staff for activities of daily living, including being incontinent for bowel and bladder. The care plan for the resident specifically noted the need for the call light to be within reach to prevent falls and ensure prompt assistance. Interviews with staff, including CNAs, an LVN, the DON, the Administrator, and the ADON, revealed that the call light was not placed within reach, contrary to the facility's policy. Staff acknowledged the importance of having the call light accessible to prevent falls and ensure timely care, especially in emergencies. Despite having received training and in-service education on the importance of call light accessibility, the staff failed to adhere to these guidelines, resulting in a deficiency in accommodating the resident's 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 provide necessary grooming services to a resident who was unable to perform activities of daily living independently. The resident, a female with multiple diagnoses including hypotension, muscle weakness, glaucoma, osteoarthritis, and cerebral infarction, was observed with a significant amount of facial hair on her chin. Despite the resident expressing her desire for the hair to be removed, the staff had not addressed this grooming need. The resident's care plan indicated a need for assistance with personal care, but this was not adequately provided. Interviews with staff, including a CNA and an LVN, revealed that the responsibility for ensuring residents were groomed and presentable fell on the charge nurses. However, this responsibility was not fulfilled in the case of the resident, leading to a deficiency in maintaining her personal hygiene and dignity. The facility's policy on activities of daily living emphasized the importance of providing care to assist residents in achieving the highest practicable outcome, which was not met in this instance.

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 administer gastrostomy feedings to Resident #66 at the prescribed rate of 50 ml/hr, instead providing feedings at 45 ml/hr. This discrepancy was observed on two separate occasions, with the resident receiving Jevity 1.5 cal at 45 ml/hr along with a water flush at 30 ml/hr. The resident, a female with a history of cerebral infarction, dysphagia, and other medical conditions, was at risk of not receiving the required daily nutritional intake, potentially leading to weight loss. The resident's care plan and physician orders specified the correct feeding rate, but the facility did not adhere to these instructions. Interviews with facility staff revealed that the error occurred because the nurse on duty relied on the facility's 24-hour report sheet rather than checking the physician's orders. The nurse admitted to not following the six rights of medication administration, which contributed to the oversight. The Director of Nursing confirmed that the resident's feedings should have been administered at 50 ml/hr, and the dietician corroborated that the feedings were ordered at this rate. The facility's policy on nutritional and dietary supplements emphasized maintaining residents' nutritional status, but this policy was not followed in this instance.

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, specifically in the management of oxygen equipment. An undated oxygen humidifier bottle was found at the bedside of a resident who was not coded for oxygen therapy in their care plan or physician orders. This oversight placed the resident at risk for cross-contamination and infections. The resident, a male with a history of dementia, Tourette's disorder, adult failure to thrive, and sepsis, was observed with an oxygen machine and humidifier bottle that lacked proper dating, indicating when it was last changed. Interviews with the Director of Nursing (DON) and the Licensed Vocational Nurse (LVN) responsible for the unit revealed that respiratory equipment should be dated and changed weekly for infection control purposes. However, the LVN admitted to monitoring the equipment daily without a specific schedule. The facility was unable to provide their infection control policy when requested by the surveyor, further highlighting the deficiency in managing respiratory care and infection control protocols.

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 proper pharmaceutical services for a resident, specifically in the administration of Dorzolamide Hydrochloride Ophthalmic solution. During a medication administration observation, a medication aide (MA A) was seen administering the eye drops directly onto the resident's eyeball instead of the lower eyelid, which is necessary for proper absorption and effectiveness. The resident, who was cognitively intact, instructed the aide not to touch her eyes, leading the aide to administer the medication incorrectly. The aide acknowledged that she knew the improper administration could be ineffective and potentially harmful. The Director of Nursing (DON) confirmed that eye drops should be administered to the lower eyelid for proper absorption and effectiveness. The facility's policy on the administration of eye drops was not followed, as it clearly states that drops should be placed in the conjunctival sac, not directly on the eyeball. The DON mentioned that the system for monitoring medication administration accuracy was conducted by the Pharmacy Consultant, but no log was available. The facility's training document showed that the aide had been marked satisfactory in medication pass competency, yet the deficiency occurred.

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 a medication error rate below 5%, resulting in a 7% error rate based on three errors out of 40 opportunities. These errors involved three residents who did not receive their medications as prescribed. Medication Aide (MA A) was responsible for these errors, which included incorrect dosages of Cyanocobalamin, Vitamin D, and Cetirizine Hydrochloride being administered to the residents. Resident #13, a cognitively intact female with multiple health conditions including type 2 diabetes and vitamin B12 deficiency anemia, was given a 500mg dose of B12 instead of the prescribed 1000mg. Resident #43, also cognitively intact and suffering from severe protein-calorie malnutrition and major depressive disorder, received a 25mcg dose of Vitamin D instead of the prescribed 50mcg. Resident #18, who has acute respiratory failure and bipolar disorder, was administered a 10mg dose of Cetirizine Hydrochloride instead of the prescribed 5mg. Interviews with MA A revealed that she was aware of the importance of correct medication dosages but was nervous during administration. The Director of Nursing (DON) and other staff members confirmed the expectation of following medication rights and acknowledged the potential for harm if incorrect dosages are given. The facility's policy requires medications to be administered as prescribed, with checks to ensure the right resident, medication, dosage, time, and method of 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 ensure that drugs and biologicals used in the facility were labeled in accordance with professional principles. Specifically, the medication carts on the 300 hall contained nasal spray, topical gels, and ointments that were opened but not labeled with the resident's name or the date they were opened. This oversight was observed during a survey, where several medications, including Diclofenac Sodium Topical Gel, Triamcinolone Acetonide, Nystatin Ointment, Clobetasol Propionate, Voltaren Arthritis Pain Gel, Tacrolimus Ointment, and Fluticasone Propionate Nasal Spray, were found to be open without the required dating. During interviews, LVN C was unaware that the gels were not dated upon opening, which is necessary to track the opening date and ensure the medication's potency within the 30-day period. The Director of Nursing (DON) confirmed that the facility lacked a policy regarding medication labeling, and the open date stickers were placed by the pharmacist as a requirement to help nurses know when to discard the medications. The facility pharmacist reiterated the importance of placing open dates on gels and ointments to assist nurses in managing medication potency 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 provide necessary services for a resident who was unable to perform activities of daily living (ADLs), specifically in maintaining personal grooming and skin care. The resident, a male with anoxic brain damage, pressure ulcers, diabetes mellitus, and hypertension, was dependent on staff for ADLs. Observations revealed that the resident had dry, patchy, and flaky skin on his left leg and foot, which was not adequately addressed by the facility staff. Interviews with the wound care nurse, Director of Nursing (DON), and other staff members indicated that the aides were responsible for showering residents and applying lotion to their skin. However, the resident's skin remained dry and flaky, suggesting that the care plan was not being followed consistently. The wound care nurse and other staff members were unaware of the resident's refusal to shower or apply lotion, and the DON was not informed about the resident's skin condition until it was observed during the survey. The facility's policy required weekly skin assessments and the application of moisturizer as needed, but these measures were not effectively implemented. The Licensed Vocational Nurse (LVN) acknowledged that the lotion used was not effective and had not informed the physician about the resident's skin condition. The Assistant Director of Nursing (ADON) and other staff members were also unaware of the resident's refusal of ADL care, indicating a lack of communication and monitoring within the facility.

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 a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the Wound Care Nurse did not follow proper wound care procedures during a dressing change for a resident with a stage 4 pressure ulcer on the sacrum. The resident, who had a history of anoxic brain damage, diabetes mellitus, and hypertension, was dependent on staff for activities of daily living and had recently completed a course of antibiotics for a wound infection. During an observation, the Wound Care Nurse was seen using the same gauze multiple times to clean different sections of the wound bed, which is against proper wound care protocol. The nurse also failed to clean the peri-wound area, which was covered with drainage, before applying a new dressing. The nurse admitted to forgetting to clean the wound bed and acknowledged that improper cleaning could lead to infection. The nurse also mentioned a lack of wound care certification and training, as well as uncertainty about who monitored her wound care practices. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Manager revealed that the Wound Care Nurse did not adhere to the facility's wound care policy, which requires using a new gauze for each cleaning stroke and cleaning the peri-wound area. The DON and ADON confirmed that improper wound cleaning could slow the healing process and increase the risk of infection. The facility's policy on wound treatment management emphasizes the importance of following physician orders and using the correct cleansing methods and dressings.

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 effective infection control program, as evidenced by the actions of the Wound Care Nurse during the treatment of a resident with a stage 4 pressure ulcer. The resident, a male with a history of anoxic brain damage, diabetes mellitus, and hypertension, was dependent on staff for activities of daily living and had a significant pressure ulcer on the sacrum. During an observation, the Wound Care Nurse did not follow proper infection control procedures, such as using a single gauze for multiple cleaning strokes and failing to clean the peri-wound area, which could lead to infection. The Wound Care Nurse admitted to not realizing the improper cleaning technique and acknowledged the potential for causing injury and infection to the wound. The nurse also mentioned a lack of wound care certification and training, as well as uncertainty about who monitored the wound care practices. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the nurse's actions were not in line with the facility's infection control policies, which require using a new gauze for each cleaning stroke and ensuring the peri-wound area is cleaned to prevent cross-contamination. Interviews with the DON, ADON, and Unit Manager highlighted the importance of proper wound cleaning techniques to prevent infection and promote healing. The facility's policy on infection control and wound treatment management emphasizes the need for adherence to physician orders and proper cleansing methods. Despite the facility's established policies, the Wound Care Nurse's actions during the wound care treatment did not align with these guidelines, potentially compromising the resident's 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 comprehensive care plan for a resident, identified as CR #1, who was admitted with multiple medical conditions including end-stage renal disease, Type 2 Diabetes, and an acquired absence of the right leg below the knee. The resident's Minimum Data Set (MDS) assessment indicated a need for supervision and assistance with activities of daily living (ADLs), as well as a risk for developing pressure ulcers. Despite these identified needs, the resident's care plan did not address wound care or ADL self-care performance deficits. On November 6, 2024, a physician's order was received to treat a pressure injury on the resident's left medial heel. However, the care plan was not updated to include this new wound care requirement. Interviews with facility staff, including two Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that the responsibility for updating the care plan was not clearly executed. The wound care nurse was expected to inform the DON of any changes, and the DON was responsible for ensuring the care plan was updated within 24 hours. This lack of timely updates posed a risk of inadequate care for the resident. The facility's policy mandates the development and implementation of a comprehensive, person-centered care plan that includes measurable objectives and timeframes. The policy also requires the care plan to be reviewed and revised after each comprehensive and quarterly MDS assessment. Despite these guidelines, the facility did not adhere to its policy, resulting in a deficiency in the care provided to the resident, as the care plan was not updated to reflect the resident's current needs and conditions.

Penalty

Inspection fine: $182,9889 days payment denial

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 protect a resident from sexual abuse, as evidenced by the resident being found with unexplained vaginal bleeding on two occasions. The resident, who had a primary diagnosis of cerebral infarction due to embolism and severely impaired cognitive skills, was first noted to have vaginal bleeding on September 14, 2024. Despite this, the facility did not take immediate action to investigate the cause or report the incident as potential abuse. The resident was later found with more severe bleeding on September 24, 2024, which led to her being transferred to a hospital where semen was found in her urine culture, and an acute injury was identified during a genital exam. Interviews and record reviews revealed that the facility staff, including nurses and CNAs, observed the bleeding but did not report it as a potential abuse case to the Administrator or follow the facility's policy for abuse prevention and investigation. The staff failed to recognize the signs of potential sexual abuse, such as the resident's refusal of peri care and fear of being touched, which were not adequately addressed or reported. The facility's open-door policy for visitors and lack of proper monitoring further contributed to the failure to protect the resident from potential abuse. The facility's Administrator and IDON were not made aware of the severity of the situation until after the resident was transferred to the hospital and the State Survey Agency notified them of the findings. The facility's lack of immediate and appropriate response to the initial signs of abuse, as well as the failure to follow established protocols for reporting and investigating potential abuse, resulted in a deficiency that placed the resident at risk of serious harm.

Removal Plan

• The facility administrator completed a self-report incident to HHSC due to allegation of sexual abuse.
• A police report was made, they arrived at the facility to collect resident demographics.
• The facility nursing management staff initiated skin assessment focusing on peri-area to ensure no trauma or signs of physical injuries were present in all residents - no issues noted.
• The facility DON/Designee assessed male residents who can ambulate, self-transfer, and who wander in the facility and other residents' rooms. One resident was placed on 1:1 supervision due to wandering. Discharge process initiated due to wandering behaviors.
• The facility Adm/DON/SW or designee initiated 1:1 interviews with facility staff and residents focusing on observation prior to the resident transfer to the hospital. Questionnaire revealed no unusual circumstances noted by staff or residents.
• The facility Social Worker/Designee conducted life safety interviews with all interviewable residents. Interviews revealed no new negative events.
• The IDON/Designee initiated an in-service with the facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect, and sexual abuse and symptoms.
• The IDON/Designee initiated an in-service with the facility staff on Possible Signs and Symptoms of Sexual Abuse including indicators, how to detect sexual abuse.
• The IDON/Designee initiated an in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting, and documentation.

Penalty

Inspection fine: $182,9889 days payment denial

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 implement its written policies and procedures to prevent abuse, as evidenced by the case of a resident who was assessed with vaginal bleeding and other signs of potential sexual abuse. The resident, who had impaired cognitive function and thought processes, was found with vaginal bleeding on two separate occasions. Despite these findings, the facility staff did not report the incidents to the Administrator or conduct a thorough investigation. The resident was eventually transferred to a hospital, where a urine sample revealed the presence of semen, and a forensic examination indicated signs of potential sexual abuse. Interviews and record reviews revealed that the facility staff, including nurses and CNAs, were aware of the resident's condition but failed to recognize or report it as a potential case of abuse. The staff did not complete incident reports or notify the Administrator, who was the designated abuse coordinator. The facility's open-door policy for visitors and lack of monitoring further contributed to the oversight. The Administrator and IDON were not informed of the situation until after the resident was transferred to the hospital, and the facility did not take immediate steps to investigate or prevent further incidents. The facility's failure to adhere to its abuse prevention policies placed residents at risk for abuse, neglect, and mistreatment. The lack of timely reporting and investigation of the resident's condition resulted in an Immediate Jeopardy finding, indicating a serious threat to resident safety. The facility's inaction and inadequate response to the situation highlight significant deficiencies in its abuse prevention and reporting protocols.

Penalty

Inspection fine: $182,9889 days payment denial

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 suspected abuse, neglect, or mistreatment in a timely manner, as required by state law and facility policy. A resident, who was cognitively impaired and unable to make decisions, was found with unexplained vaginal bleeding on two separate occasions. On the first occasion, the bleeding was noted by a CNA and reported to an RN, who then notified the Nurse Practitioner and the Assistant Director of Nursing but failed to report the incident to the facility's Abuse Coordinator. On the second occasion, the resident was found with significant vaginal bleeding and was transferred to a hospital, where semen was found in her urine sample, indicating possible sexual abuse. Despite these findings, the incident was not reported to the Abuse Coordinator or other authorities as required. Interviews with facility staff revealed a lack of understanding and adherence to the facility's abuse reporting policies. Several staff members, including CNAs, RNs, and the Interim Director of Nursing, failed to recognize the signs of potential sexual abuse and did not report the incidents to the facility's Abuse Coordinator. The Administrator, who was also the Abuse Coordinator, was unaware of the incidents until informed by the State Survey Agency. The facility's policy required immediate reporting of suspected abuse to the Administrator and other officials, but this was not followed, leading to a delay in addressing the potential abuse. The facility's failure to report the incidents promptly resulted in an Immediate Jeopardy situation, as identified by the surveyors. The lack of timely reporting and investigation of the incidents placed residents at risk for further abuse, neglect, or mistreatment. The facility's policies and procedures for reporting and investigating abuse were not effectively implemented, as evidenced by the staff's failure to report the incidents and the Administrator's lack of awareness of the situation.

Removal Plan

• The facility administrator completed a self-report incident to HHSC due to allegation of sexual abuse.
• A police report was made, they arrived at the facility to collect resident demographics.
• The facility nursing management staff initiated skin assessment focusing on peri-area to ensure no trauma or signs of physical injuries were present in all residents - no issues noted.
• The facility DON/Designee assessed male residents who can ambulate, self-transfer and who wander in the facility and other residents' rooms. One resident was placed on 1:1 supervision due to wandering. Discharge process initiated.
• The facility Adm/DON/SW or designee initiated 1:1 interviews with facility staff and residents focusing on observation prior to the resident transfer to the hospital. Questionnaire revealed no unusual circumstances noted by staff or residents.
• The facility Social Worker/Designee conducted life safety interviews with all interviewable residents. Interviews revealed no new negative events.
• The President of Operation conducted an in-service with the facility Administrator: Review of State Reportable guidelines Provider Letter to ensure understanding of reportable incidents including timeline, i.e.: Abuse is to be reported immediately but no later than 2 hours.
• The IDON/Designee initiated an in-service with the facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect and sexual abuse and symptoms.
• The IDON/Designee initiated an in-service with the facility staff on Possible Signs and Symptoms of Sexual Abuse including indicators, how to detect sexual abuse.
• The IDON/Designee initiated an in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting, and documentation.
• The IDON/Designee initiated an in-service with facility staff on: Who is the facility abuse prevention coordinator, notifications of suspected abuse and neglect including sexual abuse signs and symptoms are to be reported to the administrator immediately.
• The DON/Designee initiated an in-service with staff on immediately reporting any new residents' unusual behaviors, fear, crying, guarding, complaint of pain in pelvic area, isolation, etc.
• Any staff member not present or in service will not be allowed to assume their duties until in-serviced. Ongoing in-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, PRN, and agency staff is completed.
• The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire.
• An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved.

Penalty

Inspection fine: $182,9889 days payment denial

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 report alleged violations of abuse or mistreatment for a resident who was assessed with unexplained vaginal bleeding and other signs of potential sexual abuse. The resident, who had impaired cognitive function and was unable to make decisions, was found with vaginal bleeding on two separate occasions. Despite these findings, the facility's Administrator, who was responsible for investigating and reporting abuse incidents, did not initiate a thorough investigation or report the incidents as potential abuse. The resident was eventually transferred to a local hospital, where a urine sample revealed the presence of semen, and a forensic examination indicated signs of potential sexual assault. However, the facility did not have any incident or accident reports for the resident during the time frame of the alleged incidents. Interviews with staff revealed that many were not aware of the need to report the bleeding as a potential sign of abuse, and several staff members who had contact with the resident were not interviewed or asked to provide witness statements as part of the investigation. The facility's failure to investigate and report these incidents in a timely and thorough manner placed the resident at risk of continued abuse and further harm. The Administrator and other staff members did not follow the facility's policy for investigating and reporting abuse, which requires immediate investigation and documentation of all allegations. This lack of action and oversight led to an Immediate Jeopardy situation, as identified by the State Survey Agency.

Penalty

Inspection fine: $182,9889 days payment denial

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 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not notify the hospice nurse, EMS, and local hospital that a resident required assessment for sexual abuse after being observed with vaginal bleeding, a potential sign of sexual abuse. The resident was transferred to the hospital without the necessary information being communicated, leading to a delay in the assessment for sexual abuse. The resident in question was an elderly female on hospice care with a primary diagnosis of traumatic subdural hemorrhage. During routine care, a nurse and a CNA observed vaginal bleeding with clots, but there were no signs of distress. The facility's staff failed to communicate the suspicion of sexual abuse to the hospital, EMS, or hospice, which was crucial for the hospital to conduct a proper assessment upon the resident's arrival. The hospital staff was not informed of the potential for sexual abuse until later, which could have impacted the timeliness and accuracy of the assessment. Additionally, the facility failed to arrange emergency transportation for another resident in respiratory distress, resulting in a significant delay in the resident's arrival at the hospital. This delay in transportation and the lack of communication regarding the potential for sexual abuse in the first case highlight deficiencies in the facility's processes for handling emergencies and suspected abuse cases.

Removal Plan

• The facility administrator completed a self-report incident to HHSC due to suspected sexual abuse case.
• A Police report was made to the HCSO Case#:535847, Deputy: [name of Deputy]
• The facility nursing management staff initiated assessments focusing on peri-area to ensure no trauma of s/s of physical injuries were present in all residents- no issues noted.
• The Admin/Don/Designee collected statements from staff who had worked with the resident indicating observation of resident status and any other unusual events. No unusual events were reported.
• The facility Social Worker/Designee initiated Life safety interviews with all interviewable residents. Interviews revealed no new negative events.
• The Adm/Don conducted a 1:1 in-service with the licensed nurse assigned to Resident #2 to ensure understanding of facility expectation to call and give report to the hospital/EMS/responsible party and hospice is provided prior to the transfer. Report should include status of the resident and reason for transfer.
• The administrator established communication with the resident attending physician and the facility medical director to inform her about the vaginal bleeding with suspected sexual abuse.
• The administrator and DON met with resident #2 responsible party to ensure understanding of reason for transfer and the vaginal bleeding with suspected sexual abuse.
• The facility DON verbally informed resident #2 hospice nurse of the reason for transfer, vaginal bleeding with suspicion of sexual abuse.
• The facility marketing director went to the hospital to follow up on resident #2 status.
• The facility DON/Designee initiated a 1:1 in-service with the licensed nurses to ensure understanding on facility expectations to call report the hospital on reference to the resident status and reason for the transfer. This in-service included reporting and disclosing suspicion of sexual abuse to the hospital, EMS, MD/NP, Responsible Party and Hospice.
• The DON/Designee initiated 1:1 in-service with each license nurse on the steps to follow when a resident is suspected to be the victim of sexual abuse, report required prior transferring residents to the hospital, and who to disclose that information.
• The DON/Designee initiated in-service with the facility licensed nurses on Transfer/discharged Report. This report is printed out by the nurse/designee, the nurse then writes the reason for transfer at the bottom of the page and turns it into EMS who is to submit to the hospital.
• The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility licensed nurses. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire.
• An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval.

Penalty

Inspection fine: $182,9889 days payment denial

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 notify the primary care physician and the responsible party of a resident's change in condition, specifically difficulty breathing and signs of a seizure. The resident, a female with a history of mild unspecified dementia, Down syndrome, hypothyroidism, generalized anxiety disorder, and unspecified convulsions, was observed having difficulty breathing and was not promptly provided with emergency medical care. The resident was eventually transferred to a local hospital at the family's request, where she was diagnosed with a massive intracerebral hemorrhage, acute hypoxic respiratory failure, pneumonia, and other conditions, leading to her death. The report details that the Licensed Vocational Nurse (LVN) G did not notify the resident's primary care physician or the responsible party about the resident's respiratory distress and seizure activity. Despite being alerted by a family member and a Certified Nursing Assistant (CNA) about the resident's labored breathing, LVN G did not take immediate action to contact emergency services or the physician. Instead, non-emergency transportation was arranged, which delayed the resident's transfer to the hospital. Interviews with staff and family members revealed that the resident's condition was not adequately assessed or communicated to the necessary parties. The facility's policy required immediate notification of the physician and responsible party in the event of a significant change in condition, which was not followed. The delay in addressing the resident's respiratory distress and the failure to use emergency medical services contributed to the resident's deteriorating condition and eventual death.

Penalty

Inspection fine: $182,9889 days payment denial

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 effectively and efficiently use its resources to ensure the highest practicable well-being of its residents, as evidenced by the mishandling of abuse allegations involving two residents. The Administrator, who also served as the facility's abuse coordinator, did not thoroughly investigate or accurately report an allegation of sexual abuse concerning a resident who exhibited signs of potential abuse, including vaginal bleeding and the presence of semen in a urine sample. Despite these alarming findings, there was no immediate investigation or reporting to the appropriate authorities, leaving the resident at risk. Another resident was allegedly abused by a hired sitter, but the facility again failed to conduct a thorough investigation or report the incident. The resident had a history of seizures and was at risk for injury, yet there were no progress notes or skin assessments completed by the assigned nurse on the date of the alleged abuse. The facility's records did not reflect any investigation or reporting to the State Survey Agency, further indicating a lack of proper administrative oversight and response to potential abuse incidents. Interviews with staff revealed a lack of communication and reporting regarding the incidents. Many staff members were unaware of the ongoing investigations and had not been interviewed or asked to provide witness statements. The facility did not initiate immediate skin assessments or increased monitoring, and there was no evidence of efforts to exclude potential perpetrators from the facility. The Administrator and other key personnel failed to take timely and appropriate actions to address the serious allegations of abuse, compromising the safety and well-being of the residents involved.

Penalty

Inspection fine: $182,9889 days payment denial

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 all drugs and biologicals were stored in accordance with accepted professional principles, specifically in locked compartments. During an observation, LVN AJ was found asleep at a desk on the 400 hall with the medication cart for the 100/400 hall left unlocked. This situation persisted for approximately five minutes until LVN AJ was awakened and proceeded to lock the cart. The unlocked cart posed a risk as it could have allowed unauthorized access to medications, potentially leading to drug diversion or accidental administration to residents. Interviews with the IDON, Medical Director, and Consultant Pharmacist confirmed the importance of keeping medication carts locked when not in use. The IDON stated that LVN AJ was terminated for sleeping while the cart was unsecured, emphasizing the risk of unauthorized individuals, including residents, accessing the medications. The Consultant Pharmacist conducted an in-service and checked the carts to ensure locks were functioning, confirming that no medications were missing. The facility's policy on medication storage mandates that all drugs and biologicals be stored in locked compartments to ensure security and prevent unauthorized access.

Penalty

Inspection fine: $22,205

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 personnel provided basic life support, including CPR, to a resident requiring emergency care prior to the arrival of medical personnel. This deficiency was identified when a resident, who was a full code, was found unresponsive, and there was a delay in initiating CPR. The incident occurred at 3:41 p.m. when the resident was discovered unresponsive, but CPR was not initiated until 3:44 p.m., resulting in a three-minute delay. The resident involved was an elderly female with a history of dementia, psychotic disturbance, paroxysmal atrial fibrillation, aphasia, and contracture. Her care plan indicated she had a guardianship and was a full code, meaning she should have received CPR immediately upon being found unresponsive. However, despite the presence of staff, CPR was not initiated promptly. Video surveillance showed that staff members entered the room, but CPR was not started until several minutes later. Interviews with staff revealed discrepancies in their accounts of the events. A CNA reported notifying an LVN about the resident's difficulty breathing, but the LVN claimed she was only informed once. Another LVN did not initiate CPR, citing the resident's air mattress as a barrier. The facility's policy required staff to follow American Heart Association guidelines and provide CPR before emergency services arrived, which was not adhered to in this case.