Inspection Reports for Houston Transitional Care
8550 Jason St, Houston, TX 77074, United States, TX, 77074
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Jun 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including improper catheter care risking urinary tract infections, incorrect oxygen administration settings for residents, medication administration errors risking double dosing, improper garbage disposal, and lapses in infection prevention and control practices.
Deficiencies (5)
Failure to ensure appropriate care for residents with indwelling Foley catheters, including improper placement of Foley bag during wound care.
Failure to ensure oxygen was set according to physician orders for residents requiring respiratory therapy.
Failure to provide pharmaceutical services ensuring accurate medication administration, including a near double dose medication error and failure to document medication start date.
Failure to properly secure dumpster door, risking infection and pest exposure.
Failure to maintain infection prevention and control program, including improper hand hygiene and glove use by staff, improper storage of clean linen, and failure to sanitize medication containers.
Report Facts
Residents reviewed for incontinent care: 3
Residents reviewed for respiratory therapy: 4
Residents reviewed for pharmacy services: 9
Dumpster capacity: 0.25
Residents affected by infection control deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN M | Licensed Vocational Nurse | Named in oxygen administration findings for Residents #10 and #11 |
| RN A | Registered Nurse | Named in medication administration error involving Resident #36 |
| LVN A | Licensed Vocational Nurse | Named in medication administration error involving Resident #36 |
| CNA K | Certified Nursing Assistant | Named in infection control deficiency during incontinent care for Resident #24 |
| CMA N | Certified Medication Aide | Named in infection control deficiencies related to medication administration for Residents #20 and #24 |
| Laundry aide A | Named in infection control deficiency related to hand washing technique | |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies and monitoring |
| ADON | Assistant Director of Nursing | Mentioned in monitoring nursing staff |
| Wound care nurse | Named in catheter care deficiency | |
| Dietary Manager | Dietary Manager | Interviewed regarding dumpster door |
| Administrator | Administrator | Interviewed regarding dumpster door |
| Maintenance director | Maintenance Director | Interviewed regarding clean linen storage and hand washing observation |
| MD | Medical Doctor | Interviewed regarding medication administration and oxygen orders |
Inspection Report
Routine
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The inspection was conducted to assess the facility's pharmaceutical services, specifically to ensure accurate acquiring, receiving, dispensing, and administering of medications to meet residents' needs.
Findings
The facility failed to properly store and handle eye drops for Resident #44, as an opened bottle of Dorzolamide-Timolol eye drops was stored uncapped in a medication cart, risking contamination and potential eye infections. The nursing staff were expected to recap eye drops properly and order new medication if bottles were not sealed.
Deficiencies (1)
Failure to provide pharmaceutical services including proper storage and handling of eye drops, resulting in an uncapped eye drop bottle stored in the medication cart.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Staff member who improperly stored and administered eye drops uncapped. | |
| DON | Director of Nursing | Interviewed regarding expectations for eye drop storage and infection control in-service. |
Inspection Report
Routine
Deficiencies: 4
Date: May 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to baseline care plans, pharmaceutical services, food service safety, and garbage disposal.
Findings
The facility failed to complete baseline care plans within the required 48-hour timeframe for several residents, failed to properly store and handle medications (specifically eye drops), failed to store the ice machine scoop in a covered container, and failed to properly close dumpster doors, potentially exposing residents to risks such as inadequate care, infections, cross-contamination, and vermin exposure.
Deficiencies (4)
Failed to develop and implement a baseline care plan within 48 hours for 4 residents, including incomplete social services sections.
Failed to provide pharmaceutical services meeting needs of residents; eye drops stored uncapped risking contamination.
Failed to store ice machine scoop in a covered container, risking cross contamination and food-borne illness.
Failed to properly dispose of garbage; dumpster side doors left open risking exposure to germs and vermin.
Report Facts
Residents reviewed for baseline care plans: 8
Residents affected by baseline care plan deficiency: 4
Staff members reviewed for pharmacy services: 1
Facility kitchen reviewed for ice scoop storage: 1
Waste receptacle reviewed for garbage disposal: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Named in medication storage and administration deficiency related to uncapped eye drops |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding baseline care plan timeframe and medication storage expectations |
| Social Services Assistant | Social Services Assistant | Responsible for completing social services portion of baseline care plan |
| Dietary Manager | Dietary Manager | Interviewed regarding ice scoop storage and dumpster door closure |
| Cook | Cook | Interviewed regarding dumpster door closure |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 10, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to provide wound care as ordered, improper feeding tube care, medication administration errors, improper medication storage, food storage violations, and infection control breaches.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to wound care, feeding tube care, medication administration, medication and food storage, and infection control practices.
Findings
The facility failed to ensure proper wound care was provided to Resident #62, failed to provide appropriate feeding tube care for Resident #33, improperly administered medication to Resident #39 by crushing a delayed release medication, failed to store medications and food according to professional standards, and failed to maintain infection control practices during wound care and incontinent care.
Deficiencies (6)
Failure to ensure Resident #62 received wound care treatment daily as ordered, with missed wound care on weekends.
Failure to provide appropriate care for Resident #33 with gastrostomy tube, including improper handling of feeding pump by untrained CNA.
Failure to administer medication correctly to Resident #39 by crushing Protonix delayed release granules.
Failure to ensure proper labeling, storage, and expiration monitoring of medications in medication carts and medication room.
Failure to store food items off the floor in dry storage, walk-in cooler, and walk-in freezer.
Failure to maintain infection prevention and control practices by wound care nurse and CNA, including failure to change gloves and perform hand hygiene.
Report Facts
Residents reviewed for care plans: 14
Residents reviewed for gastrostomy tube: 3
Residents reviewed for pharmacy services: 4
Dates wound care missed: 3
BIMS score: 15
BIMS score: 3
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN G | Licensed Vocational Nurse | Interviewed about wound care responsibilities and risks of missed wound care. |
| Wound Care Nurse | Interviewed about wound care orders and weekend coverage; observed failing to change gloves during wound care. | |
| DON | Director of Nursing | Interviewed about wound care documentation, staffing issues, medication administration errors, medication storage, and infection control observations. |
| LVN W | Licensed Vocational Nurse | Interviewed about wound care on weekends and documentation. |
| LVN O | Licensed Vocational Nurse | Observed and interviewed regarding medication administration error crushing Protonix DR granules and medication cart storage. |
| CNA P | Certified Nursing Assistant | Observed and interviewed regarding improper feeding pump handling and failure to perform hand hygiene during incontinent care. |
| LVN I | Licensed Vocational Nurse | Interviewed about medication storage and feeding pump handling. |
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