Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 6
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of practice related to IV fluid administration, respiratory care, pharmaceutical services, food preferences, food safety, and infection prevention and control at Garden Terrace Alzheimer's Center of Excellence.
Findings
The facility failed to ensure safe administration of IV fluids, proper respiratory care including oxygen equipment maintenance, pharmaceutical services including disposal of expired medications, adherence to resident dietary preferences, food safety standards in the kitchen, and infection prevention and control practices including PPE use and hand hygiene.
Deficiencies (6)
Failure to ensure safe and appropriate administration of IV fluids including failure to attach needleless connectors, disinfect midline catheters, date dressings, and wear appropriate PPE.
Failure to ensure respiratory care including changing humidifier water and oxygen tubing according to facility policy.
Failure to provide pharmaceutical services including disposal of expired medications and maintaining medication storage conditions.
Failure to accommodate resident dietary preferences resulting in serving meat to a vegetarian resident.
Failure to maintain food safety in the kitchen including staff not wearing hair nets, improperly stored and dated food items, dented cans, uncovered melted fat, cleaning equipment placed against clean dishes, cross-contamination risks in nourishment refrigerators, and fans blowing towards food areas.
Failure to implement infection prevention and control program including failure to wear PPE during enhanced barrier precautions and failure to perform hand hygiene by staff.
Report Facts
Deficiencies cited: 6
Oxygen flow rate: 5
Temperature: 30
Date of survey completion: Nov 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN G | Registered Nurse | Named in IV fluid administration deficiencies for Resident #81 |
| LVN F | Licensed Vocational Nurse | Named in IV fluid administration and infection control deficiencies for Residents #15 and #25 |
| LVN I | Licensed Vocational Nurse | Interviewed regarding IV fluid administration and infection control |
| CNA J | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene |
| DON | Director of Nursing | Interviewed regarding infection control and IV fluid administration |
| ADON | Assistant Director of Nursing | Interviewed regarding infection control, IV fluid administration, and pharmaceutical services |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and dietary preference deficiencies |
| Dietitian | Dietitian | Interviewed regarding dietary preferences and meal preparation |
| Dietary aide D | Dietary Aide | Named in food safety deficiencies for not wearing hair net and improper food storage |
| Dietary aide C | Dietary Aide | Interviewed regarding food safety practices |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to assess compliance with resident dignity and respect during meal service and to ensure adequate supervision and safety measures to prevent accidents related to medication disposal.
Findings
The facility failed to treat residents with dignity during lunch service by staff standing while feeding residents instead of sitting, contrary to facility policy. Additionally, the facility failed to ensure adequate supervision and safe disposal of medication syringes, which were found exposed in trash cans accessible to confused residents, posing a risk of accidents.
Deficiencies (2)
Failure to treat residents with respect and dignity during lunch service by standing while feeding instead of sitting as per facility policy.
Failure to ensure adequate supervision and safe disposal of medication syringes left exposed in trash cans accessible to residents.
Report Facts
Residents affected: 10
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Named in findings related to feeding residents while standing and inadequate supervision of medication disposal | |
| CNA B | Named in findings related to feeding residents while standing and inadequate supervision of medication disposal |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement policies and procedures to prevent neglect, specifically related to an unwitnessed fall and injury of Resident #1 on 03/28/2024.
Complaint Details
The complaint investigation focused on Resident #1's unwitnessed fall on 03/28/24, which resulted in bleeding on the brain. The facility did not report the injury as required and failed to thoroughly investigate the injury of origin. Interviews revealed the Administrator and DON did not consider the fall a reportable event due to perceived lack of serious injury, contrary to hospital findings.
Findings
The facility failed to implement written policies and procedures to prevent neglect, resulting in Resident #1 sustaining a serious injury from a fall that was not properly investigated or reported. Additionally, the facility failed to secure medication carts, leaving them unlocked and unattended, placing residents at risk for unauthorized access to medications.
Deficiencies (2)
Failed to implement policies and procedures to prevent abuse, neglect, and theft, resulting in neglect of Resident #1 who sustained a serious injury from a fall that was not properly investigated or reported.
Failed to properly secure medications in locked compartments; medication carts were left unlocked and unattended, risking unauthorized access.
Report Facts
Resident fall risk score: 16
Date of fall: Mar 28, 2024
Date of survey completion: Apr 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN L | Licensed Vocational Nurse | Completed Resident #1's Fall Risk Evaluation and conducted assessment after fall |
| LVN V | Licensed Vocational Nurse | Responsible for medication cart left unlocked during observation |
| LVN E | Licensed Vocational Nurse | Interviewed regarding medication cart security |
| Administrator | Facility Administrator and Abuse Coordinator who failed to report injury and did not consider fall reportable | |
| DON | Director of Nursing | Failed to implement policies and did not report injury; interviewed regarding fall and medication cart responsibility |
| Medical Records Director | Observed and locked medication cart; unaware of medication administration policy | |
| Hospital Nurse | Reported Resident #1's MRI revealed new bleeding on the brain from the fall |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 1, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with respiratory care standards for residents requiring oxygen therapy and related respiratory equipment management.
Findings
The facility failed to ensure that oxygen tubing and CPAP tubing for five residents (#1, #3, #5, #7, and #9) were properly labeled, dated, and stored, which could place residents at risk of improper oxygen delivery, cross contamination, respiratory compromise, and infection.
Deficiencies (2)
Failure to ensure oxygen tubing was labeled and dated for Residents #1, #3, #5, #7, and #9.
Failure to ensure CPAP tubing was dated and properly stored when not in use for Residents #1, #3, and #9.
Report Facts
Residents affected: 5
Tubing change frequency: 7
Oxygen flow rate: 2
Oxygen flow rate: 5
BIMS scores: 15
BIMS scores: 13
BIMS scores: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Registered Nurse | Interviewed about responsibility for changing respiratory tubing every Sunday and monitoring oxygen levels and tubing dates |
| DON | Director of Nursing | Interviewed about in-service training on tubing change and monitoring, responsible for auditing tubing changes and dates |
| ADM | Administrator | Interviewed about expectations for nursing staff to monitor care and equipment according to policy |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Date: Dec 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the physician and family of a significant change in a resident's condition after an alleged fall during transfer, resulting in multiple fractures.
Complaint Details
The complaint investigation was triggered by family reports that Resident #1 was dropped during transfer on 11/24/23, resulting in multiple fractured ribs and a sternum fracture discovered after hospital admission on 11/27/23. The nurse failed to report or assess the incident properly, and the facility was unaware of the injury until hospital notification. An Immediate Jeopardy was identified on 12/14/23 and removed on 12/15/23 with ongoing monitoring.
Findings
The facility failed to immediately notify the physician and resident's representative of a significant change in Resident #1's condition after she was allegedly dropped during transfer, resulting in multiple fractured ribs and a sternum fracture. The nurse involved did not perform a full assessment or report the incident, leading to an Immediate Jeopardy that was later removed but with continued noncompliance at actual harm level. The facility implemented staff training and monitoring to prevent recurrence.
Deficiencies (5)
Failure to immediately notify the physician and resident's representative of significant change in Resident #1's condition after alleged fall during transfer.
Failure to ensure residents' right to be free from neglect; failure to report and assess Resident #1's fall.
Failure to ensure the residents' environment remains free of accident hazards and provide adequate supervision to prevent accidents for Resident #1.
Failure to provide pharmaceutical services including accurate narcotic counts and correct medication administration for Residents #2 and #7.
Failure to ensure drugs and biologicals were stored in locked compartments and monitored during medication pass for Resident #7.
Report Facts
Residents reviewed for physician notification: 37
Discrepancy in narcotic tablets: 10
Residents reviewed for pharmacy services: 8
Residents affected by deficiencies: 1
Residents affected by medication deficiencies: 2
Residents affected by medication storage deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Registered Nurse | Failed to notify physician and family of Resident #1's fall and condition change; failed to perform full body assessment; involved in narcotic count discrepancy |
| RN M | Registered Nurse | Administered incorrect medication dosage to Resident #7; left medication unattended during medication pass |
| RN A | Registered Nurse | Counted narcotics with LVN B and identified discrepancy on 11/30/23 |
| LVN B | Licensed Vocational Nurse | Counted narcotics with RN A and identified discrepancy on 11/30/23 |
| LVN C | Licensed Vocational Nurse | Observed administering medications and narcotic count on 12/15/23 |
| CNA E | Certified Nursing Assistant | Assisted with transfer of Resident #1 from wheelchair to bed on 11/24/23 |
| Transportation driver R | Transportation Driver | Assisted with transfer of Resident #1 from wheelchair to bed on 11/24/23 |
| Administrator | Administrator | Interviewed regarding incident and facility corrective actions |
| Physician | Physician | Notified late of Resident #1's condition change; unaware of fall |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care planning, kitchen sanitation, infection prevention and control, and other facility operations at Garden Terrace Alzheimer's Center of Excellence.
Findings
The facility failed to develop and implement baseline care plans within 48 hours for new admissions, failed to ensure kitchen staff wore appropriate hair and beard restraints and properly labeled food items, and failed to follow infection prevention policies including proper PPE use and timely replacement of sharps containers. These deficiencies posed risks of decreased quality of care, foodborne illness, and exposure to infectious agents.
Deficiencies (4)
Failed to create and implement a baseline care plan within 48 hours for Resident #12.
Failed to ensure kitchen staff wore appropriate hair and beard restraints.
Failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately.
Failed to ensure staff followed infection prevention policy for Resident #11 including proper PPE use and sharps container management.
Report Facts
Residents reviewed for care plans: 6
Residents affected: 1
Residents affected: 3
Sharps containers reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse B | Confirmed baseline care plan for Resident #12 was not completed until 9/30/2023 | |
| DON | Director of Nursing | Explained baseline care plan process and cited internet outage as reason for delay |
| Activity Assistant A | Observed not wearing hairnet in kitchen | |
| LVN-A | Licensed Vocational Nurse and Infection Preventionist | Stated PPE was required for residents on Enhanced Barrier Precautions and responsible for changing sharps containers |
| CNA-B | Certified Nursing Assistant | Observed carrying isolation cabinets to residents on Enhanced Barrier Precautions |
| Dietician | Explained importance of hair restraints and food dating in kitchen |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 15, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with staffing requirements for the food and nutrition service, specifically evaluating the qualifications of kitchen staff.
Findings
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. The Maintenance Supervisor, who lacked proper certification and training, was acting as the Dietary Manager and serving food to residents, which could increase the risk of foodborne illness and inadequate nutrition.
Deficiencies (1)
Failure to employ sufficient staff with appropriate competencies and skills to carry out food and nutrition service functions, including a qualified dietician. The Dietary Manager did not have the appropriate license or certification, and the Maintenance Supervisor served as the Dietary Manager without certification or training.
Report Facts
Residents Affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Acted as Dietary Manager without proper certification or training, served food on 02/12/23 and 02/13/23 | |
| ADM | Interviewed regarding the Maintenance Supervisor's role and staffing issues |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 15, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with staffing requirements for the food and nutrition service, specifically evaluating the qualifications of kitchen staff.
Findings
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. The Maintenance Supervisor, who lacked proper certification and training, was acting as the Dietary Manager and serving food to residents, which could increase the risk of foodborne illness and inadequate nutrition.
Deficiencies (1)
Failed to employ sufficient staff with appropriate competencies and skills for food and nutrition service; Maintenance Supervisor acting as Dietary Manager without proper certification or training.
Report Facts
Duration Maintenance Supervisor served as Dietary Manager: 2
Dates Maintenance Supervisor served as cook/server: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Acted as Dietary Manager and served food without proper certification or training | |
| ADM | Interviewed regarding staffing and Dietary Manager position |
Inspection Report
Deficiencies: 0
Date: Aug 11, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Garden Terrace Alzheimer's Center of Excellence, summarizing the findings of a regulatory survey completed on 08/11/2022.
Findings
No health deficiencies were found during the survey.
Viewing
Loading inspection reports...
