Inspection Reports for North Houston Transitional Care
9814 Grant Rd, Houston, TX 77070, United States, TX, 77070
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for North Houston Transitional Care, summarizing the findings from the survey completed on 2025-04-30.
Findings
No health deficiencies were found during the survey.
Inspection Report
Deficiencies: 2
Date: Aug 28, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations, specifically ensuring that drugs and biologicals are stored in locked compartments and labeled according to professional standards.
Findings
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 2 of 3 residents reviewed. Specifically, Clotrimazole 1% cream was found at Resident #3's bedside without a physician's order, and a medication cup with barrier cream was found at Resident #12's bedside contrary to facility policy.
Deficiencies (2)
Failure to ensure Resident #3 did not have Clotrimazole 1% cream on his nightstand near the bedside.
Failure to ensure Resident #12 did not have a medication cup filled with unidentified white barrier cream on the bedside tray parallel to the bed.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Interviewed regarding medication found at Resident #3's bedside and stated she would bring medications to the nurse and not leave them at bedside. |
| Interim DON | Interim Director of Nursing | Provided interviews about medication storage policies and family bringing cream for Resident #3. |
| Therapy Tech | Therapy Technician | Reported rounding on Resident #3's room and not seeing medication on the nightstand. |
| CNA A | Certified Nursing Assistant | Interviewed about barrier cream found in Resident #12's room and its usual storage. |
| Wound Care Nurse | Wound Care Nurse | Interviewed about the barrier cream used for Resident #12 and stated she applied it herself and it should not be left in the room. |
| ADON | Assistant Director of Nursing | Discussed staff training and in-services related to barrier cream storage and staff responsibilities. |
| Administrator | Facility Administrator | Discussed facility rounds and education provided to staff and residents' families about medication storage. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to immediately inform or consult with a resident's physician upon significant change in condition, resulting in resident death.
Complaint Details
The complaint involved failure to notify a resident's physician of a significant change in condition, failure to monitor the resident adequately, and failure to provide appropriate wound care and infection control, resulting in resident death and risk of infection.
Findings
The facility failed to notify the physician of a resident in respiratory distress with low oxygen saturation, failed to monitor the resident adequately, and failed to follow wound care and infection control protocols, resulting in resident death and risk of infection.
Deficiencies (4)
Failure to immediately inform or consult with the resident's physician upon significant change in condition, resulting in resident death.
Failure to ensure residents received treatment and care according to professional standards and care plans, including inadequate monitoring of respiratory distress.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to follow physician's wound care orders and failure to transcribe wound care doctor's order.
Failure to implement an infection prevention and control program, including failure to perform hand hygiene during wound care.
Report Facts
Oxygen saturation: 73
Oxygen saturation: 93
Deficiency count: 4
Stage 3 pressure ulcers: 2
Stage 4 pressure ulcers: 2
Wound size: 0.4
Wound size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Failed to notify physician of resident's respiratory distress and failed to monitor resident adequately; resigned after incident. |
| CNA B | Certified Nursing Assistant | Observed resident's respiratory distress and nasal cannula displacement but did not notify nursing staff. |
| LVN Z | Licensed Vocational Nurse | Provided wound care without proper hand hygiene and failed to follow physician's wound care orders. |
| DON | Director of Nursing | Interviewed regarding incident and facility protocols; stated LVN A did not notify her timely. |
| ADON | Assistant Director of Nursing | Interviewed regarding incident and wound care observation; certified infection preventionist. |
| OT | Occupational Therapist | Discovered resident unresponsive and noted nasal cannula was not in place. |
| CNA AA | Certified Nursing Assistant | Assisted LVN Z with wound care and changed resident twice on observation day. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident who fell out of bed because the air mattress was not securely strapped to the bed frame.
Complaint Details
The complaint investigation found that the resident (CR #1) fell out of bed on 4/19/24 due to the air mattress not being secured to the bed frame. The resident was sent to the hospital for evaluation but had no injuries. Interviews with staff and family confirmed the fall and identified maintenance staff as responsible for securing the air mattresses. The facility performed a facility-wide air mattress sweep and staff in-service training following the incident.
Findings
The facility failed to ensure the resident environment was free from accident hazards, specifically failing to secure an air mattress to the bed frame, resulting in a resident falling to the floor and being sent to the hospital for evaluation. The facility conducted a sweep of air mattresses and provided staff training after the incident.
Deficiencies (1)
Failed to securely strap resident's air mattress to the bed frame, causing a fall.
Report Facts
Residents reviewed for accident hazards: 5
Residents affected: 1
Pressure ulcers: 3
Weight: 122.4
Blood Pressure: 114
Pulse: 112
Respiratory Rate: 18
Temperature: 98.6
Air mattresses accounted for: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Nurse who found resident on floor and documented fall |
| MD A | Physician | Physician who documented resident status prior to fall |
| DON | Director of Nursing | Provided interview about air mattress procedures and staff training |
| ADM | Administrator | Provided interview about expectations for air mattress maintenance and safety |
| Maintenance Director | Former staff responsible for securing air mattresses, no longer employed |
Inspection Report
Deficiencies: 2
Date: Feb 22, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically assessing whether comprehensive, person-centered care plans were developed and implemented for residents.
Findings
The facility failed to develop comprehensive care plans for 2 of 14 residents, specifically Resident #10 and Resident #53, resulting in risks of inadequate medical care. Resident #10's care plan did not address nutritional deficits, functional status, bladder and bowel status, heart disease, and respiratory failure. Resident #53's care plan did not document the need for foley catheter use and dialysis.
Deficiencies (2)
Failure to develop a comprehensive person-centered care plan for Resident #10 addressing nutritional deficits, functional status, bladder and bowel status, heart related disease, and respiratory failure.
Failure to develop a comprehensive person-centered care plan for Resident #53 addressing foley catheter use and dialysis.
Report Facts
Residents affected: 2
BIMS score: 15
BIMS score: 14
Care Plan Review Dates: Nov 15, 2023
Admission Date: Nov 6, 2023
Readmission Date: Jan 17, 2024
Dialysis Frequency: 3
Inspection Report
Deficiencies: 2
Date: Feb 22, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to determine if comprehensive, person-centered care plans were developed and implemented for residents.
Findings
The facility failed to develop comprehensive care plans for 2 of 14 residents, specifically Resident #10 and Resident #53, resulting in risks of inadequate medical care. Resident #10's care plan did not adequately address nutritional deficits, functional status, bladder and bowel status, heart-related disease, and respiratory failure. Resident #53's care plan did not document the need for foley catheter use and dialysis.
Deficiencies (2)
Failure to develop a comprehensive person-centered care plan for Resident #10 addressing nutritional deficits, functional status, bladder and bowel status, heart related disease, and respiratory failure.
Failure to develop a comprehensive person-centered care plan for Resident #53 addressing foley catheter use and dialysis.
Report Facts
Residents affected: 2
BIMS score: 15
BIMS score: 14
Walking distance: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 2/22/2024 regarding care plan purpose and creation. | |
| Assistant Director of Nursing | Interviewed on 2/22/2024 regarding impact of missing or outdated care plans. | |
| Interim Director of Nursing | Interviewed on 2/22/2024 regarding importance of care planning for treatments such as dialysis and catheter use. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
The document is an annual inspection report for North Houston Transitional Care, summarizing the findings of the survey completed on December 1, 2022.
Findings
No health deficiencies were found during the inspection.
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