Inspection Reports for Mason Creek Transitional Care of Katy

The inspection was conducted to assess compliance with regulatory standards related to resident care, medication administration, food safety, infection control, and pest control at Mason Creek Transitional Care of Katy.

The facility was found deficient in developing and implementing comprehensive care plans, safe administration of IV fluids, accurate pharmaceutical services, food safety and storage, infection prevention and control, and pest control. Specific issues included failure to update care plans for midline care, improper midline dressing changes, medication administration errors, unlabeled and improperly stored food, failure to sanitize blood pressure equipment, and presence of pests in the kitchen.

The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately consult with a resident's physician after a significant change in condition and failure to provide appropriate respiratory care.

The facility failed to notify the physician or seek medical guidance when the resident experienced a drop in oxygen saturation during physical therapy and a shower, resulting in drastic desaturation, loss of consciousness, CPR, intubation, and eventual death. The facility also failed to accurately document oxygen orders and ensure proper oxygen administration and monitoring during care.

The complaint investigation was triggered by a report that the facility failed to immediately consult with the resident's physician after a significant change in condition, failed to increase oxygen during exertion, and failed to monitor oxygen administration, resulting in the resident's drastic desaturation, cardiac arrest, and death.

The inspection was conducted due to a complaint investigation regarding alleged physical abuse of Resident #1 by LVN B on 12/05/2023.

The facility failed to prevent physical abuse of Resident #1 by LVN B, which was substantiated by video evidence and staff interviews. LVN B was terminated following the investigation. The facility implemented interventions including staff education on abuse/neglect, safe surveys, and background checks.

The complaint was substantiated. The abuse incident involved LVN B forcefully pushing Resident #1's wheelchair and intimidating her. The facility reported the incident to HHSC, suspended and terminated LVN B, notified the physician, responsible party, and sheriff's department, and conducted staff in-services on abuse/neglect.

The inspection was conducted based on a complaint regarding inadequate incontinent care provided to Resident #60, specifically failure to ensure appropriate treatment and services to prevent urinary tract infections and restore continence.

The facility failed to ensure that CNA M properly cleaned Resident #60 during incontinent care, including failure to wash hands before care, improper use of wipes, and inadequate cleaning of the labia and abdominal folds, which could place residents at risk for pain, infection, injury, and hospitalization.

The complaint investigation found that CNA M did not wash or sanitize hands before care, used the same gloves and wipes improperly, did not separate or clean Resident #60's labia or abdominal folds, increasing risk of infection and skin breakdown. Interviews with CNA M, DON, and ADON confirmed expectations and deficiencies. CNA M had signed perineal care training in November 2023.

The inspection was conducted based on a complaint investigation regarding the facility's failure to provide timely incontinent care and grooming to Resident #60, and concerns about food safety and garbage disposal.

The facility failed to provide timely incontinent care and proper grooming to Resident #60, resulting in dry, flaky skin and potential risk for skin breakdown. Additionally, the facility failed to properly store and dispose of food items in the kitchen, including expired cheeses and improperly stored scoops, and failed to secure dumpster lids, posing risks of infection and foodborne illness.

The complaint investigation focused on Resident #60's care related to incontinent care and grooming. The investigation found substantiated failures in timely incontinent care and grooming, with interviews from Resident #60, CNAs, DON, and ADON confirming lapses in care. Additional findings included food safety violations and improper garbage disposal.

The inspection was conducted to assess the facility's compliance with food storage and labeling standards as part of regulatory oversight.

The facility failed to store food in accordance with professional standards by having unlabeled food items in the refrigerator and freezer, which posed a potential risk of foodborne illness to residents.