Deficiencies (last 3 years)
Deficiencies (over 3 years)
18.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
434% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 12
Date: Jun 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication management, staff training, and facility environment.
Findings
The facility was found deficient in multiple areas including resident dignity during care, accommodation of resident needs, environmental hazards, nutritional monitoring, respiratory care, pharmaceutical services, medication storage, food safety, medical record accuracy, infection control practices, and staff training compliance.
Deficiencies (12)
Failure to ensure Resident #66 was treated with dignity during dining room observation.
Failure to ensure Resident #18's call light was within reach while positioned on her bed.
Failure to maintain resident environment free of accident hazards for Residents #22, #49, and #39.
Failure to measure Resident #16's weight on re-admission as ordered.
Failure to ensure Resident #27's nebulizer mask was covered in a plastic bag when not in use.
Failure to provide pharmaceutical services meeting needs of residents; opened Omeprazole capsule administered via gastrostomy tube contrary to label instructions; expired suction catheter kits found in medication rooms.
Failure to ensure insulin pens for Residents #46 and #238 had open dates to track expiration.
Failure to date prepared and poured beverages and cereal in kitchen storage areas.
Failure to maintain complete and accurate medical records; inaccurate documentation of Resident #16's mechanically altered diet.
Failure to establish and maintain infection control program; observed staff failing to follow infection control practices including glove use and gown use for enhanced barrier precautions.
Failure to develop, implement, and maintain effective training program ensuring required trainings upon hire and annually for multiple staff including communication, resident rights, abuse prevention, infection control, ethics, QAPI, and behavioral health.
Failure to ensure nurse aides received required minimum 12 hours annual in-service training.
Report Facts
Residents reviewed for environmental hazards: 24
Residents reviewed for nutrition status maintenance: 5
Residents reviewed for respiratory care: 3
Residents reviewed for pharmacy services: 13
Residents reviewed for medication storage: 20
Residents reviewed for medical records: 20
Residents reviewed for infection control practices: 20
Employees reviewed for training requirements: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN-G | Licensed Vocational Nurse | Administered medication contrary to label instructions and failed to wear gown during enhanced barrier precaution care |
| CNA D | Certified Nursing Assistant | Failed to change gloves and perform hand hygiene between contaminated and clean tasks |
| CNA-I | Certified Nursing Assistant | Failed to change gloves when providing peri care |
| ADON-B | Assistant Director of Nursing | Provided statements regarding dignity, feeding, infection control, and training deficiencies |
| DON | Director of Nursing | Provided statements regarding dignity, equipment maintenance, and infection control |
| LVN-H | Licensed Vocational Nurse | Noted insulin pens without open dates and lack of knowledge about discarding them |
| Regional RN | Regional Registered Nurse | Acknowledged expired suction catheter kits and trays found in medication rooms |
| HR Representative | Human Resources Representative | Provided information about training program deficiencies and responsibilities |
| Administrator | Facility Administrator | Provided information about training program deficiencies and responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of sexual abuse involving Resident #1 by a CNA.
Complaint Details
The complaint involved an allegation of sexual abuse of Resident #1 by a CNA. The allegation was made by the resident's responsible party and family members. The facility did not report the allegation to law enforcement immediately but filed a report after surveyor inquiry. The resident was sent to the ER for assessment with no findings of sexual abuse. The facility suspended the CNA and initiated an internal investigation. The allegation was substantiated as a failure to timely report.
Findings
The facility failed to report the alleged sexual abuse to local law enforcement immediately, as required, resulting in delayed investigation. The resident was assessed in the hospital with no finding of sexual abuse, but the facility did not notify law enforcement until after surveyor inquiry. The facility initiated internal investigation and suspended the CNA involved.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents affected: 1
Date of incident: May 11, 2025
Date of hospital report: May 13, 2025
Date of police report: May 13, 2025
Date facility reported to law enforcement: May 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Notified of alleged abuse on 5/13/25, responsible for reporting to law enforcement, delayed notification until 5/15/25 | |
| DON | Director of Nursing | Participated in interviews, stated no psychosocial harm to resident, involved in internal investigation |
| LVN E | Licensed Vocational Nurse | Described facility procedure for abuse allegations including immediate assessment and notification |
| LVN H | Licensed Vocational Nurse | Attended ANE training, stated reporting procedures and role of Administrator as Abuse Coordinator |
| Hospital Nurse | Conducted hospital assessment of Resident #1 on 5/13/25 | |
| MD | Medical Doctor | Notified of alleged abuse, saw resident prior to incident, involved in assessment and orders |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 9, 2025
Visit Reason
The inspection was conducted due to complaints and allegations regarding drug diversion, abuse reporting failures, elopement, accident hazards, and pharmaceutical service deficiencies at Wurzbach Nursing and Rehabilitation.
Complaint Details
The investigation was complaint-driven based on allegations of drug diversion, failure to report abuse, elopement, unsafe resident transfer, and pharmaceutical service deficiencies. The drug diversion involved missing narcotics for Residents #5 and #6. The facility failed to report an abuse incident involving Residents #3 and #4 timely. Resident #1 eloped from the facility, and Resident #2 was injured during transfer. The facility's pharmaceutical services failed to ensure accurate medication acquisition and administration.
Findings
The facility failed to prevent drug diversion of narcotic medications for two residents, failed to timely report an abuse incident involving two residents, failed to prevent elopement of a resident, failed to ensure safe transfer of a resident resulting in injury, and failed to provide pharmaceutical services ensuring accurate medication acquisition and dispensing. The facility identified missing narcotics, inadequate reporting of abuse, and unsafe resident supervision and transfer practices.
Deficiencies (4)
Failed to ensure residents had the right to be free of misappropriation of resident property and exploitation; narcotic medications for Residents #5 and #6 were missing due to drug diversion.
Failed to report to the state survey agency an incident where Resident #4 hit Resident #3 on the head on 9/27/2024 within the required 2-hour timeframe.
Failed to ensure the resident environment was free from accident hazards and provide adequate supervision to prevent accidents; Resident #1 eloped from the facility and Resident #2 was injured during an unsafe transfer.
Failed to provide pharmaceutical services to meet the needs of residents; Residents #5 and #6 did not receive prescribed pain medications due to drug diversion and inadequate medication delivery and documentation procedures.
Report Facts
Missing narcotic tablets: 208
Missing narcotic tablets: 15
Missing narcotic doses: 30
Missing narcotic doses: 118
Missing narcotic doses: 15
Distance eloped: 0.2
Staff involved in drug diversion investigation: 6
Staff in-serviced on elopement: 100
Staff interviewed on in-servicing: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Named in drug diversion investigation and suspected responsible for Resident #5's missing medications |
| RN G | Registered Nurse | Reported suspicion of drug diversion and involved in medication cart handover |
| LVN F | Licensed Vocational Nurse | Suspected responsible for Resident #6's missing medications |
| LVN H | Licensed Vocational Nurse | Named in drug diversion investigation |
| LVN K | Licensed Vocational Nurse | Named in drug diversion investigation |
| LVN L | Licensed Vocational Nurse | Named in drug diversion investigation |
| LVN M | Licensed Vocational Nurse | Named in drug diversion investigation |
| CNA A | Certified Nursing Assistant | Involved in unsafe transfer causing injury to Resident #2; employment terminated |
| LVN B | Licensed Vocational Nurse | Witnessed abuse incident involving Residents #3 and #4 |
| DON | Director of Nursing | Led drug diversion investigation and acknowledged failures in medication delivery and abuse reporting |
| Administrator | Facility Administrator | Led drug diversion investigation and acknowledged failures in medication delivery and abuse reporting |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 6, 2024
Visit Reason
The inspection was conducted to evaluate the facility's pharmaceutical services, specifically the procedures ensuring accurate acquiring, dispensing, and administering of all drugs and biologicals to meet resident needs.
Findings
The facility failed to ensure accurate documentation of administration times for scheduled controlled medications for three residents, which could place residents at risk for medication overdose, under-dose, ineffective therapeutic outcomes, and drug diversion. The medication aide (MA A) documented administration times as scheduled times rather than actual administration times and had not been trained on proper documentation procedures.
Deficiencies (3)
Failure to accurately document administration times for scheduled pain medication Tramadol HCl Oral Tablet 50 mg for Resident #1.
Failure to accurately document administration times for scheduled pain medication Tramadol HCl Oral Tablet 50 mg for Resident #2.
Failure to accurately document administration times for scheduled pain medication Tylenol with Codeine #3 Tablet 300-30 mg and anti-anxiety medication Diazepam Oral Tablet 2 mg for Resident #3.
Report Facts
Residents affected: 3
Medication administration times observed: 3
In-service date: Dec 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Medication Aide | Named in findings for inaccurate documentation of medication administration times and lack of training on Controlled Substance Administration Records |
| DON | Director of Nursing | Provided interview regarding proper documentation procedures and in-service training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately inform a resident's physician of a significant change in condition and failure to maintain complete and accurate medical records for multiple residents.
Complaint Details
The complaint investigation focused on Resident #1's worsening wound and failure to notify the physician timely. The investigation found the wound worsened over the weekend without proper notification to the physician or treatment nurse. Interviews with staff and review of records confirmed failures in communication and documentation.
Findings
The facility failed to notify the physician timely about Resident #1's worsening wound, resulting in potential risk for delayed treatment. Additionally, the facility failed to document wound and skin treatments for multiple residents on numerous occasions, risking inadequate care and oversight.
Deficiencies (2)
Failed to immediately inform Resident #1's physician of a significant change in condition related to a worsening wound.
Failed to maintain complete, accurate, and accessible medical records for 5 residents, including failure to document wound and skin treatments on multiple occasions.
Report Facts
Missed wound care documentation occasions: 5
Missed skin treatment documentation occasions: 6
Missed wound care documentation occasions: 34
Missed wound care documentation occasions: 2
Missed wound care documentation occasions: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD A | Attending Physician | Named in failure to notify physician of Resident #1's worsening wound |
| NP D | Nurse Practitioner | Wound NP involved in Resident #1's wound care and notification process |
| LPN E | Treatment Nurse | Responsible for notifying physician of wound or skin condition changes; attempts to contact unsuccessful |
| LPN F | Nurse | Involved in wound care for Resident #1; attempts to contact unsuccessful |
| RN C | Weekend Supervisor Nurse | Responsible for ensuring treatments were done on weekends |
| DON | Director of Nursing | Provided statements on wound condition changes and treatment documentation expectations |
| ADMIN | Administrator | Provided statements on reporting responsibilities and treatment documentation |
| LPN G | Nurse | Provided statements on wound care documentation and treatment processes |
| RN I | Hospice Nurse | Interviewed regarding Resident #4's wound care |
| RN J | Hospice Nurse | Interviewed regarding Resident #5's wound care |
| ADON | Assistant Director of Nursing | Provided statements on treatment documentation and TAR blanks |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately inform Resident #1 and notify the resident's representative of a significant change in the resident's health status on 08/14/2024.
Complaint Details
The complaint investigation found that Resident #1's representative was not notified of the resident's change of condition on 08/14/2024, including new orders for medications and oxygen. The representative only learned of the condition upon visiting on 08/17/2024 when Resident #1 was transferred to the hospital. The facility reported an allegation of neglect to the state agency and implemented corrective actions including staff training and supervision of LVN A.
Findings
The facility failed to notify Resident #1's representative of the resident's episodic high blood pressure and new medication orders on 08/14/2024, which could place residents at risk by not reporting health status changes and denying consent opportunities. LVN A documented the change and new orders but did not report to the representative. The facility conducted an investigation, provided staff training, and identified no other similar deficiencies.
Deficiencies (1)
Failure to immediately inform the resident and notify the resident's representative of a significant change in the resident's physical, mental, or psychosocial status and/or need to alter treatment significantly.
Report Facts
Date of change of condition: Aug 14, 2024
Medication dosage: 10
Medication dosage: 4
Oxygen flow rate: 2
Vital sign - Oxygen saturation: 84
Vital sign - Heart rate: 112
Vital sign - Blood pressure: 198
Vital sign - Blood pressure: 98
Vital sign - Respiratory rate: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Documented change of condition and new orders but failed to notify Resident #1's representative; received further training and supervision |
| ADON | Assistant Director of Nursing | Reported findings to DON and Administrator, coordinated investigation and corrective actions |
| DON | Director of Nursing | Involved in investigation and corrective actions |
| Administrator | Facility Administrator | Conducted investigation, reported allegation of neglect to state agency, and implemented corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and thoroughly investigate allegations of abuse, neglect, and misappropriation involving Resident #56.
Complaint Details
The complaint investigation focused on Resident #56, who had an unwitnessed fall resulting in a skin tear and hematoma. The facility did not report the incident timely and failed to conduct a thorough investigation, including obtaining witness statements. Interviews with staff including LVN B and the Director of Nursing revealed inconsistencies and incomplete documentation regarding the fall and investigation.
Findings
The facility failed to report an unwitnessed fall with injury of Resident #56 to the State Survey Agency within the required timeframe and did not thoroughly investigate the incident. The resident was found with a skin tear and hematoma, and the investigation lacked witness statements and a complete report.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft involving Resident #56 within 2 hours to the State Survey Agency.
Failed to thoroughly investigate alleged violations of resident abuse, neglect, exploitation, or mistreatment for Resident #56.
Report Facts
Residents assessed for reporting allegations: 6
Residents reviewed for abuse and neglect: 8
Date of Resident #56's fall incident report: Mar 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Created Nurse's Note on 3/29/2024 and reported Resident #56's fall and injuries. |
| DON | Director of Nursing | Interviewed multiple times regarding the fall investigation and witness statements for Resident #56. |
| Administrator | Provided statements regarding the completeness of the incident report and reporting policies. |
Inspection Report
Routine
Deficiencies: 11
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to develop and implement policies to prevent abuse, failure to timely report and investigate abuse allegations, failure to provide written bed-hold policy to residents, failure to complete discharge assessments and summaries, failure to ensure physician orders for oxygen, failure to administer medications as ordered, failure to date insulin pens, and failure to maintain proper infection control practices.
Deficiencies (11)
Failed to develop and implement written policies and procedures to prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to thoroughly investigate all alleged violations of resident abuse, neglect, exploitation, or mistreatment.
Failed to provide written information to the resident or resident representative about the bed-hold policy before transfer to hospital or therapeutic leave.
Failed to ensure each resident receives an accurate assessment; specifically, a discharge MDS was not completed for a discharged resident.
Failed to ensure a discharge summary was completed for a discharged resident.
Failed to ensure a resident who needed respiratory care had physician orders for oxygen administration.
Failed to provide pharmaceutical services to meet the needs of each resident; specifically, medications Tylenol and Senexon were not administered as ordered.
Failed to ensure residents were free from significant medication errors; specifically, Midodrine was administered outside of physician parameters.
Failed to ensure drugs and biologicals were labeled and stored properly; specifically, insulin pens were not dated when opened.
Failed to maintain an infection control program; specifically, staff failed to change gloves appropriately, wash hands or use hand sanitizer between glove changes, and wear proper PPE during wound care.
Report Facts
Medication administration errors: 2
Midodrine administration out of parameters: 7
Insulin pens not dated: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Named in infection control and medication administration findings |
| LVN D | Licensed Vocational Nurse | Named in medication administration findings |
| LVN F | Licensed Vocational Nurse | Named in medication administration findings |
| LVN G | Licensed Vocational Nurse | Named in medication administration findings |
| LVN H | Licensed Vocational Nurse | Named in medication administration findings |
| Administrator | Named in multiple interviews related to findings | |
| DON | Director of Nursing | Named in multiple interviews related to findings |
| RN A | Registered Nurse, Infection Preventionist | Named in infection control findings |
| ADON | Assistant Director of Nursing | Named in infection control findings |
| Admin Coor. | Admissions Coordinator | Named in bed hold policy findings |
| BOM | Business Office Manager | Named in bed hold policy findings |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Apr 16, 2024
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to reasonably accommodate resident needs and preferences, specifically related to call light accessibility and food preferences/allergies for certain residents.
Complaint Details
The investigation was complaint-driven, focusing on call light accessibility issues for Residents #3, #6, and #8, and food allergy and preference issues for Residents #5 and #7. Interviews and observations confirmed the complaints were substantiated.
Findings
The facility failed to ensure call lights were within reach for 3 residents, potentially risking their safety and independence. Additionally, the facility did not honor food allergies and preferences for 2 residents, risking allergic reactions and dissatisfaction. Staff interviews confirmed lapses in call light placement and meal tray verification despite training and policies.
Deficiencies (2)
Failed to provide reasonable accommodation of resident needs and preferences for call light accessibility for 3 residents.
Failed to provide food that accommodated resident allergies and preferences for 2 residents.
Report Facts
Residents reviewed for call lights: 54
Residents affected by call light deficiency: 3
Residents reviewed for food preferences: 13
Residents affected by food preference deficiency: 2
Fall Risk Scores: 19
Fall Risk Scores: 14
Fall Risk Scores: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN MDS | Registered Nurse MDS Coordinator | Interviewed regarding call light placement and confirmed responsibility of staff to keep call lights within reach |
| CNA A | Certified Nursing Assistant | Interviewed about call light placement responsibility and training |
| DON | Director of Nursing | Interviewed about call light placement policies and staff training |
| LVN A | Licensed Vocational Nurse | Interviewed regarding meal tray verification and acknowledged missing Resident #5's allergies |
| RN A | Registered Nurse | Interviewed regarding meal tray verification and acknowledged missing Resident #7's food dislikes |
| Dietary Manager | Dietary Manager | Interviewed about food allergy and preference documentation and tray verification process |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on hand hygiene and sanitization practices during medication administration and blood pressure monitoring.
Findings
The facility failed to ensure proper hand hygiene and sanitization of blood pressure cuffs by licensed vocational nurses during medication passes for 4 of 5 residents reviewed, which could place residents at risk for cross contamination. Interviews and record reviews confirmed lapses in handwashing and equipment sanitization despite existing policies and training.
Deficiencies (3)
Failure to ensure LVN A performed hand hygiene after administering medications to Residents #1 and #2.
Failure to ensure LVN A sanitized the blood pressure cuff after taking Residents #1 and #2's blood pressures.
Failure to ensure LVN B sanitized the blood pressure cuff after taking Residents #3 and #4's blood pressures.
Report Facts
Residents reviewed for infection control: 5
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in findings for failure to perform hand hygiene and sanitize blood pressure cuff during medication pass |
| LVN B | Licensed Vocational Nurse | Named in findings for failure to sanitize blood pressure cuff during medication pass |
| RN A | Infection Preventionist | Interviewed regarding expectations for hand hygiene and sanitization practices |
| DON | Director of Nursing | Interviewed regarding expectations and training on hand hygiene and sanitization |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 1, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse and neglect, failure to provide appropriate nursing care, and failure to ensure resident safety and prevent accidents including elopement incidents.
Complaint Details
The complaint investigation found substantiated failures including delayed reporting of abuse, delayed nursing care, and inadequate supervision leading to elopements. The facility had past immediate jeopardy noncompliance related to elopement risks but had corrected the issues before the survey.
Findings
The facility failed to timely report and investigate a resident's injury of unknown origin, delayed care for an infected knee, and failed to prevent unauthorized elopements of residents due to unsecured courtyard gates. The facility had past noncompliance with immediate jeopardy status related to elopement risks but had corrected these issues prior to the survey.
Deficiencies (4)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for Resident #4's head injury of unknown origin.
Failure to provide supervision and continuity of nursing care resulting in a 2-day delay in treatment for Resident #3's infected left knee.
Failure to ensure the resident environment was free from accident hazards and provide adequate supervision to prevent accidents, resulting in unauthorized elopements of Resident #1 and Resident #6.
Failure to provide a safe, functional, sanitary, and comfortable environment by not securing the B wing courtyard back door/fence, allowing public access and resident elopement risk.
Report Facts
Residents reviewed for injuries of unknown source: 5
Residents reviewed for continuity of nursing care: 5
Residents reviewed for accident hazards and supervision: 9
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Named in failure to report Resident #4's head injury and in elopement incident interviews. |
| RN D | Registered Nurse | Named in delayed care for Resident #3's infected knee and reporting neglect to DON. |
| DON | Director of Nursing | Named in multiple interviews regarding reporting failures and nursing care supervision. |
| Administrator | Named in interviews regarding facility policies and elopement prevention. | |
| LVN F | Licensed Vocational Nurse | Named in Resident #1 elopement incident and nursing progress notes. |
| LVN G | Licensed Vocational Nurse | Named in Resident #6 elopement incident and staffing concerns. |
| Maintenance Director | Named in interviews regarding fence and gate maintenance and elopement risks. | |
| Account Manager | Named in interviews regarding courtyard gate security and resident behaviors. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide basic life support, including CPR, to a resident (Resident #1) who required emergency care prior to the arrival of emergency medical personnel, contrary to physician orders and the resident's advance directives.
Complaint Details
The complaint investigation revealed that Resident #1 was found unresponsive and did not receive CPR despite the absence of a signed out-of-hospital DNR form. The family stated Resident #1 was supposed to be full code, but the facility documented him as DNR based on hospital reports and electronic medical records. Interviews with staff and administrators confirmed lack of verification of code status and missing documentation. The facility self-reported the incident and took corrective actions.
Findings
The facility failed to ensure Resident #1 received life-saving measures including CPR when found unresponsive, due to lack of a signed out-of-hospital DNR form and conflicting code status documentation. The facility self-reported the incident and implemented corrective actions including staff training, policy updates, audits, and monitoring to prevent recurrence.
Deficiencies (1)
Failure to provide basic life support, including CPR, prior to the arrival of emergency medical personnel, subject to physician orders and the resident’s advance directives.
Report Facts
Licensed nurses trained: 14
Licensed nurses on staff: 18
Licensed staff trained: 22
Licensed staff signed training: 19
Post-test questions: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Admission Nurse | Placed physician order for DNR status in electronic medical record; admitted Resident #1; interviewed regarding code status verification. |
| LVN B | Licensed Vocational Nurse | Found Resident #1 unresponsive; documented no CPR performed due to DNR status in electronic medical record; interviewed about incident. |
| Administrator | Self-reported incident to HHSC; involved in corrective actions and staff training; interviewed regarding facility processes. | |
| DON | Director of Nursing | Interviewed about incident, staff training, policy changes, and corrective actions. |
| NP | Nurse Practitioner | Interviewed; stated she did not sign any orders for Resident #1 and did not give order for code status. |
| Admissions Coordinator | Interviewed about admission process and code status verification responsibilities. | |
| SW | Social Worker | Interviewed about code status verification and post-incident audits and training. |
| Medical Director | Notified of incident; participated in QA meetings; recommended policy amendments. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 9, 2023
Visit Reason
The inspection was conducted as an annual survey of Wurzbach Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Apr 30, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Wurzbach Nursing and Rehabilitation, summarizing the findings from a regulatory survey completed on April 30, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 3, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide reasonable accommodation for a resident's orthotic support device (back brace) and failure to provide timely laboratory services for another resident.
Complaint Details
The complaint investigation focused on Resident #17's unmet need for a back brace ordered by a neurosurgeon and Resident #238's delayed urinalysis laboratory testing. Resident #17 reported chronic pain and lack of the brace since November 2022. The facility staff had not effectively communicated the issue to the attending physicians. Resident #238's urinalysis was ordered on 02/21/2023 but was not sent to the lab until 02/28/2023 due to collection difficulties and communication lapses.
Findings
The facility failed to ensure Resident #17 received a prescribed back brace due to delays in paperwork and communication with the neurosurgeon's office, resulting in actual harm. Additionally, the facility failed to send Resident #238's ordered urinalysis to the laboratory for 7 days, delaying diagnosis and treatment.
Deficiencies (2)
Failure to provide Resident #17 with a prescribed back brace due to lack of communication and paperwork delays with the neurosurgeon's office.
Failure to provide timely laboratory services for Resident #238; urinalysis was delayed by 7 days.
Report Facts
Residents reviewed: 5
Delay in urinalysis processing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Doctor L | Neurosurgeon | Ordered back brace for Resident #17 and involved in paperwork delays |
| LVN E | Licensed Vocational Nurse | Reported on Resident #17's back brace situation and communication issues |
| ADON D | Assistant Director of Nursing | Involved in attempts to secure paperwork for Resident #17's back brace |
| Medical Director | Medical Director | Facility Medical Director for Resident #17 and #238, unaware of back brace issue until survey |
| Nurse Practitioner O | Nurse Practitioner | Attending provider for Resident #17, unaware of back brace issue |
| Doctor S | Physician | Ordered urinalysis for Resident #238 |
| RN F | Registered Nurse | Involved in collection and reporting delays of Resident #238's urinalysis |
| LVN G | Licensed Vocational Nurse | Collected urine sample for Resident #238 and involved in reporting delays |
| DON | Director of Nursing | Aware of Resident #17's back brace issue and Resident #238's urinalysis delay |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 27, 2023
Visit Reason
Routine inspection of Wurzbach Nursing and Rehabilitation to assess compliance with regulatory requirements including resident dignity, grievance handling, abuse reporting, care planning, orthotic device provision, laboratory services, infection control, and call system functionality.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity by locking wheelchair unnecessarily, failure to process resident grievances timely, failure to report injuries of unknown origin, failure to develop a comprehensive care plan for a resident in the memory care unit, failure to provide an ordered back brace and communicate this to attending physicians, delay in sending laboratory urine samples, failure to follow infection control protocols during incontinent care, and failure to ensure call lights were within reach of residents.
Deficiencies (8)
Failure to treat Resident #67 with dignity by locking wheelchair after meal.
Failure to process grievances for Residents #6 and #17 timely and appropriately.
Failure to timely report injury of unknown origin for Resident #6 to state agency and guardian.
Failure to develop and implement a comprehensive care plan for Resident #47 in secured memory care unit.
Failure to provide ordered back brace for Resident #17 and failure to communicate this to attending physicians.
Failure to provide timely laboratory services for Resident #238; urinalysis delayed 7 days.
Failure of CNA A to remove gloves and perform hand hygiene when moving from contaminated to clean body sites during care of Residents #12 and #67.
Failure to ensure call lights were within reach of Residents #15 and #18.
Report Facts
Residents sampled: 46
Residents reviewed for grievances: 5
Residents reviewed for injuries of unknown origin: 5
Residents reviewed for care planning: 8
Residents reviewed for orthotic devices: 5
Residents reviewed for laboratory services: 5
Residents observed for infection control: 2
Residents reviewed for call system: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in dignity and infection control deficiencies for Residents #67 and #12 |
| LVN G | Licensed Vocational Nurse | Named in injury reporting and laboratory services deficiencies related to Resident #6 and #238 |
| Administrator | Interviewed regarding dignity and grievance processes | |
| ADON D | Assistant Director of Nursing | Interviewed regarding grievance forms and Resident #17 back brace |
| LVN E | Licensed Vocational Nurse | Interviewed regarding Resident #17 back brace and communication with physicians |
| Medical Director | Medical Director | Interviewed regarding Resident #17 back brace and Resident #238 laboratory delays |
| Nurse Practitioner O | Nurse Practitioner | Interviewed regarding Resident #17 back brace |
| RN F | Registered Nurse | Named in laboratory services and call light deficiencies |
| CNA H | Certified Nursing Assistant | Interviewed regarding call light placement for Residents #15 and #18 |
| SW | Social Worker | Interviewed regarding Resident #47 memory care assessments and Resident #17 back brace advocacy |
| RN MDS C | Registered Nurse MDS Coordinator | Interviewed regarding Resident #47 care plan |
| LVN B | Licensed Vocational Nurse | Interviewed regarding Resident #47 elopement risk and COVID history |
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