Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Feb 13, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards, including pharmaceutical services, medication administration, medication labeling and storage, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide proper pharmaceutical services such as removal of expired medication supplies, medication administration errors, improper medication labeling and storage, food safety violations including improper labeling and storage of food items and poor hand hygiene among dietary staff, and failure to follow infection control protocols for COVID-19 isolation precautions.
Deficiencies (5)
Failed to provide pharmaceutical services meeting residents' needs, including failure to remove expired medication administration supplies from medication rooms.
Failed to ensure residents were free from significant medication errors, specifically incorrect administration of clonazepam to Resident #29 for 155 days.
Failed to ensure all drugs and biologicals were labeled according to professional principles and secured properly on medication carts, including unlabeled eye drops and unlocked medication carts left unattended.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including unlabeled and expired food items, improper hand hygiene by dietary staff, and malfunctioning handwashing sink trash receptacles.
Failed to establish and maintain an infection prevention and control program, including failure of RN D to use proper infection control precautions when entering the room of a resident on droplet precautions for COVID-19.
Report Facts
Days medication error occurred: 155
Number of residents reviewed for medication errors: 19
Number of medication carts reviewed: 4
Number of residents reviewed for infection control: 3
Number of residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Named in infection control deficiency for not using proper PPE entering COVID isolation room |
| MA C | Medication Aide | Named in medication administration error involving clonazepam |
| ADON B | Assistant Director of Nursing | Named in monitoring medication rooms and infection control training |
| DON | Director of Nursing | Named in oversight of medication administration and infection control |
| NP D | Nurse Practitioner | Named in medication order transcription error |
| Central Supply | Named in responsibility for checking medication supplies expiration dates | |
| MA E | Medication Aide | Named in discussion of eye drop expiration and open dates |
| LVN F | Licensed Vocational Nurse | Named in discussion of eye drop expiration and open dates |
| MA H | Medication Aide | Named in discussion of eye drop expiration and open dates |
| RN D | Registered Nurse | Named in medication cart security deficiency |
| DM | Dietary Manager | Named in food safety deficiencies and interviews |
| ADM | Administrator | Named in food safety interview |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, food safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, improper incontinence care, failure to change respiratory tubing as scheduled, food safety violations in the kitchen, and lapses in infection prevention and control practices such as cross contamination risks and improper sanitization of equipment.
Deficiencies (5)
Failure to ensure call light system was accessible to residents #59 and #77.
Failure to provide appropriate perineal care for Resident #102 after incontinence episode.
Failure to ensure Resident #72's nebulizer tubing was changed weekly as scheduled.
Failure to ensure food in walk-in refrigerator was covered, ice machine clean, and tea covered.
Failure to maintain infection prevention and control program including cross contamination risks with insulin pen and glucometer, failure to perform hand hygiene during incontinence care, catheter bag on floor, and failure to sanitize blood pressure cuff between residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Fall risk score: 8
BIMS score: 14
BIMS score: 13
BIMS score: 11
BIMS score: 13
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in cross contamination finding with insulin pen and glucometer |
| CNA B | Certified Nursing Assistant | Named in findings related to improper incontinence care and hand hygiene |
| RN J | Registered Nurse | Interviewed regarding call light accessibility and respiratory tubing change |
| CNA G | Certified Nursing Assistant | Interviewed regarding call light accessibility |
| CNA A | Certified Nursing Assistant | Interviewed regarding call light accessibility |
| LVN P | Licensed Vocational Nurse | Interviewed regarding call light accessibility and catheter bag care |
| MA D | Medication Aide | Named in failure to sanitize blood pressure cuff between residents |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including infection control and call light accessibility |
| ADON H | Assistant Director of Nursing | Interviewed regarding respiratory tubing and catheter bag care |
| Dietary Manager | Interviewed regarding kitchen sanitation deficiencies | |
| Administrator | Interviewed regarding expectations for call light, kitchen sanitation, and infection control |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Belterra Health & Rehab following a survey completed on 11/03/2022.
Findings
No health deficiencies were found during the survey.
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