The Sarah Roberts French Home

Based on interview and record review, the facility failed to provide mandatory effective training on abuse, neglect, exploitation, and misappropriation training for 5 of 17 employees (Admissions, CNA E, Med Aide D, LVN G, ADON) reviewed for training, in that: The facility failed to ensure effective abuse, neglect, exploitation, and misappropriation training was provided to Admissions, CNA E, Med Aide D, LVN G, ADON annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for Admissions revealed a hire date of 05/31/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Abuse, Dementia, QAPI, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide mandatory effective training on standards, policies, and procedures for an infection prevention and control program training for 4 of 17 employees (Cook A, Maintenance, CNA E, Med Aide D) reviewed for training, in that: The facility failed to ensure effective standards, policies, and procedures for an infection prevention and control program training was provided [NAME] A, Maintenance, CNA E, Med Aide D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for Maintenance revealed a hire date of 02/24/2022. Further review of a training log, provided by the HR Manager revealed no evidence of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide mandatory effective training on ethics training for 4 of 17 employees (Cook A, CNA E, Med Aide D, DON) reviewed for training, in that: The facility failed to ensure effective ethics training was provided [NAME] A, CNA E, Med Aide D, DON annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Falls, Restraints, Emergency Preparedness being provided annually. Record review of personnel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 1 of 8 residents (Resident #16) reviewed for advanced directives, in that: The facility failed to ensure Resident #16's RP desire to formulate an advanced directive OOH DNR was completed and part of the medical record. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident of #16's face sheet, dated 8/30/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that dementia, type 2 diabetes mellitus (chronic health condition that affects how body turns food into energy), and chronic obstructive pulmonary disease (a group of serious lung diseases that make it hard to breathe. It's caused by damage to the lungs that narrows the airways, or bronchi, and reduces airflow). Record review of Resident #16's quarterly MDS, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 1 of 8 residents (Resident #32) whose records were reviewed for abuse and neglect: The facility failed to report to the state reporting agency (HHSC) an injury of unknown origin when Resident #32 suffered a nose fracture and was not able to say what happened. These deficient practices could affect residents by contributing to further abuse and neglect. The findings were: Record review of Resident #32's admission record revealed an [AGE] year-old female admitted [DATE] with Alzheimer's disease (a brain disorder that causes a gradual decline in memory, thinking, and the ability to perform daily tasks) and white matter disease (is a general term for damage to the white matter in the brain, which can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #16) reviewed for comprehensive care plans: The facility failed to ensure Resident #16's care plan contained a code status. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Record review of Resident of #16's face sheet, dated 8/30/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that dementia, type 2 diabetes mellitus (chronic health condition that affects how body turns food into energy), and chronic obstructive pulmonary disease (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications on 1 (central supply room) of 3 medication storage rooms and 1 (north hall crash cart) of 2 crash carts reviewed for pharmacy services. The facility failed to discard and replace expired supplies. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: During an observation on 11/06/24 at 12:29 p.m., the central supply storage room on the north hallway contained a drawer of gastrostomy tubes (A tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient. Giving food through a gastrostomy tube is a type of enteral nutrition. Also called PEG tube and percutaneous endoscopic tube.) with an expiration date of 10/26/21 and a bottle of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 3 meals observed, in that: Cook A did not ensure food prepared for residents receiving a mechanical soft diet was in the proper consistency for this diet. This deficient practice could affect residents who ate mechanical soft texture diets, and place them at-risk by contributing to choking, weight loss, and dissatisfaction. The findings were: Record review of the facility's list of resident's diets, dated 11/6/2024, revealed 23 of the 48 residents received mechanical soft diets. Observation on 11/05/2024 at 11:43 AM, revealed [NAME] A preparing mechanical soft porkchops. [NAME] A completed the process and placed the mechanical soft porkchops in a tray before placing it on the steamtable. Surveyor asked [NAME] A to stir mechanical soft porkchops. Four quarter sized pieces of porkchop was observed within the tray of mechanical soft porkchops. Interview with [NAME] A on 11/05/2024 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #13) reviewed for hospice services, in that: The facility failed to ensure Resident #13's most recent Physician Certification of Terminal Illness was completed and part of the hospice documents at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #13's face sheet, dated 11/06/24, revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 4 residents reviewed for call lights (Resident #s 1 and 2). The facility failed to ensure Residents #s 1 and 2's call light was accessible and in reach. Resident #1's call light button was observed hanging behind her mattress on the floor. Resident #2's call light button was hanging over the side of her bed and touching the floor. These failures could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs. Findings included: Resident #1 Record review of Resident #1's electronic faces sheet revealed Resident #1 was [AGE] years old and was admitted on [DATE]. Resident #1's diagnoses included the following: History of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the facility staff and hospice staff, and failed to maintain required hospice forms and documentation for 2 (Resident #12 and Resident #13) of 2 residents reviewed for hospice coordination of care, in that: The facility did not designate a member of the interdisciplinary team to act as liaison with the companies providing hospice services within the facility; the facility failed to procure current certification of terminal illness. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: 1. Record review of Resident #12's face sheet, dated 10/13/2023, revealed the resident was admitted to the facility on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's right to refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #12) of 13 residents reviewed for advanced directives, in that: The resident and her responsible party executed an OOH-DNR, and the facility was unaware. This deficient practice could result in residents receiving CPR against their wishes. The findings were: Record review of Resident #12's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: acute kidney failure, essential (primary) hypertension, and unspecified dementia. Further review revealed, Advanced Directive: Full Code. Record review of Resident #12's quarterly MDS, dated [DATE], revealed a BIMS score of 01 which indicated severe cognitive deficit. Record review of Resident #12's care plan, revised [DATE], revealed Resident is a [sic] FULL CODE Staff will inform family member/ resident of the right to request…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive assessment after a significant change for 1 (Resident #12) of 13 residents reviewed for assessments, in that: The resident enrolled in hospice services on 06/24/2023 and as of 10/13/2023, a comprehensive assessment following a significant change had not been completed. This failure could place residents at risk of caregivers with inaccurate and/or out of date information. The findings were: Record review of Resident #12's face sheet, dated 10/13/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: acute kidney failure, essential (primary) hypertension, and unspecified dementia. Further review revealed, Advanced Directive: Full Code. Record review of Resident #12's quarterly MDS, dated [DATE], revealed a BIMS score of 01 which indicated severe cognitive deficit. Further review revealed the resident was noted as receiving hospice services. Record review of Resident #12's care plan, revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 7 Residents (Resident #9) whose MDS records were reviewed for accuracy. Resident #14's Quarterly MDS assessment dated [DATE] incorrectly documented the resident was rarely/never understood and did not complete a BIMS (brief interview for mental status). This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #14's face sheet, dated 10/13/2023 revealed Resident #14 was admitted to the facility on [DATE] with diagnoses that included: anemia (a lack of red blood cells or dysfunctional red blood cells in the body. This leads to reduced oxygen flow to the body's organs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus with unspecified complications (A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #45) reviewed for incontinence/perineal care, in that: CNA E did not provide complete catheter care to Resident #45. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #45's face sheet, dated 10/13/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), dependence on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #13) reviewed for infection control practices, in that: CNA C and CNA E did not utilize appropriate hand hygiene during incontinent/catheter care to Resident #34. These failures could place residents who required incontinent/catheter care at risk for infection or a decline in health. The findings included: Record review of Resident #13's face sheet dated 10/13/2023 revealed a 77- year- old female who initially admitted on [DATE] with diagnoses that included but not limited Alzheimer's disease with early onset, type 1 diabetes, overactive bladder, legal blindness and major depressive disorder. The face sheet also noted the resident was on hospice services. Record review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately inform a resident, a resident's physician, and a resident's representative of the discharge for 1 of 1 residents (Resident #1) reviewed for notification of discharges in that: The facility did not notify Resident #1, CO E, CO F, or Resident #1' s physician of the plan to abruptly discharge Resident #1 on 9/19/23. This deficient practice could place residents, their family, and physician at risk of not being informed of discharge, resulting in a delay in medical intervention and decline in health. The findings were: Record review of Resident #1's demographics page, dated 9/20/23, revealed CO F was Resident #1's POA and Emergency Contact #2 and CO E was Resident #1's Emergency Contact #1. Record review of Resident #1's diagnoses page, dated 9/20/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with hyperglycemia [high sugar levels in the blood], hypothyroidism [when the thyroid does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services as outlined by the comprehensive care plan that meet professional standards of quality for 1 of 5 residents (Resident#1) reviewed for care plans in that: Resident #1's care plan did not include a care plan for diabetes. This deficient practice could affect diabetic residents and placed them at risk for not receiving the care and services to meet their needs. The findings were: Record review of Resident #1's diagnoses page, dated 9/20/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with hyperglycemia [high sugar levels in the blood], hypothyroidism [when the thyroid does not produce enough hormones], essential (primary) hypertension, and unspecified vision loss. Record review of Resident #1's BIMS assessment, dated 8/17/23, revealed Resident #1 had a BIMS score of 15, signifying no cognitive impairment. Record review of Resident #1's care plan, dated 1/19/23, revealed no care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to verify that professional staff is licensed, certified, or registered in accordance with applicable State laws in that: CNA A worked as a medication aid when her MA licensed was expired and had administered medications to 22 residents on [DATE]. This failure could place resident, who received medications, at risk of receiving the wrong medications or a medication error. The findings were: Record review showed CNA A's medication aid permit was issued on [DATE] and had expired [DATE]. Furthermore, according to the HHS website information, However, HHSC is extending a grace period for all NAs and MAs to allow users time to learn and understand the new credentialing system. Therefore, all NAs and MAs with certifications or permits active on [DATE], will be considered active until Oct. 31, 2023. Record review of the facility's Med Tech MAR records shows that on [DATE], CNA A electronically initialed medication administration indicating she had passed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to maintain essential patient care equipment in safe operating condition for the facility's mechanical lift for 1(South Hall mechanical Lift) of 4 mechanical lifts reviewed for essential equipment. The facility failed to restore and repair the mechanical lift's remote mechanism located on the south hall. This failure could place residents at risk who required use of a mechanical lift that is not in operable condition by increasing the risk of injury to residents. Findings included: In an observation on 8/29/2023 at 1:50 PM, - revealed the mechanical lift had loose wires at the remote connection, making the mechanical lift inoperable. Record review of mechanical lifts service record revealed that all mechanical lifts had been serviced and calibrated on 7/24/2023. Records indicated, The scales are now in good calibration and working order. We performed inspection on the listed patient lifts. (The mechanical lift in question was part of the inspection.) In an interview on 8/29/2023 at 12:19 PM with CNA C stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.