Houston Transitional Care

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 2 residents (Resident#1 and Resident#2) and 1 of 1 staff (Wound Care Nurse) reviewed for infection control. - The facility failed to ensure the Wound Care Nurse washed or sanitized her hands and performed glove changes appropriately while providing wound care to Resident #1 and Resident #2 on 06/24/26. This failure placed residents with wounds or infection at risk for cross contamination and the spread of infection. Record review Resident # 1's face sheet dated 6/24/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review 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 7 residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure CNA A changed gloves and completed hand hygiene when providing care to Resident #1.2. CNA B failed to don appropriate PPE (disposable gown) prior to providing direct care to Resident #1, who was on EBP. These failures could place residents at risk for cross contamination, infections, and unwanted hospitalization. Record review of Resident #1's face sheet, dated 05/28/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure the residents were given the right to participate in the development and implementation of their plans of care for 2 of 17 residents (Resident #1, Resident #16) reviewed for participating in care planning. The facility did not conduct a meeting nor invite Resident #16 to participate in resident care planning meetings after his quarterly review assessments on 10/9/2024, 1/9/25 and 4/11/25. The facility did not conduct a meeting nor invite Resident #1's responsible party to participate in resident care planning meetings after his quarterly review assessments on 9/5/24, 12/6/24 and 3/8/25 and after a comprehensive review assessment on 6/6/25. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 1 of 1 facility reviewed for Activity Director. The facility Activity Director was not a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place the residents at risk of not having an activities program that meets their assessed activity needs. Findings Include: In an interview on 7/17/25 at 3:56 p.m. the Activities Director said she was the Activities Director but was more like an Activities Assistant because she did not have the activity director training. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 of 2 medication fridges (West Medication Room Fridge) and 1 of 1 central supply room reviewed for storage. The facility failed to ensure that medication fridges were clean and free of food; and that expired medications were not found in the central supply room and medication fridge. The failure could place residents at risk of contamination of medications or receiving expired medications.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 17 Residents (Resident #16) reviewed for care plans. -The facility failed to develop and implement a care plan regarding Resident #16's history of self-harm and diagnosis of schizophrenia. These failures could place residents at risk of not having their needs met or inability of staff to identify a change of condition. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 2 of 17 residents (Resident #1 and #16) reviewed for ADL care. The facility failed to ensure Residents #1 and #15 received services necessary to maintain grooming, including haircuts based on their preferences. This failure could place residents at risk of not receiving care and services, discomfort, decreased quality of life, and loss of dignity.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 1 of 17 residents (Resident #1) reviewed for activities. This facility failed to implement an ongoing resident centered activities program for Resident #1 that incorporated the residents' interests, hobbies and cultural preferences. This failure could put residents at risk for a decrease quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.25% based on 2 errors out of 32 opportunities, which involved 1 of 3 residents (Resident #17) and 1 of 1 staff (MA G) observed during medication administration reviewed for medication error. 1. The facility failed to ensure Resident #17's Ferrous Gluconate 324 mg was administered as ordered as FeroSul (Ferrous Sulfate) 325 mg was administered on 7/16/25 at 8:58 a.m. 2. The facility failed to ensure Resident #17's Lidocaine 4% patch was administered as ordered as order stated patch was to be placed on sacrum (base of the spine) and was placed on right shoulder on 7/16/25 at 8:58 a.m. The failure could place residents at risk of not receiving therapeutic dosages and/or effects of medications.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, 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 and communicable disease and infections for 1 of 17 residents (Resident #5) reviewed for infection control in that: Resident #5's urinary catheter tubing was observed touching the floor twice on 7/15/2025. This failure placed residents at risk for infections and decrease in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 of 5 staff (CNA K, Wound care nurse, CMA N, and Laundry aide A ) and one(linen closet W) out of two clean linen closet observed for infection control. 1. The facility failed to ensure CNA K followed proper infection control and hand washing procedure during incontinent care for Resident #24. wound care. 2. CMA N did not sanitize the plastic medication container after using to administer medication for Resident #20 3. CMA N did not wash her hands prior to administering eye drops for Resident #24. 4. The facility failed to ensure to ensure clean item was not stored on the floor in the west clean linen closet. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #41) reviewed for incontinent care. The facility failed to ensure Resident #41's foley bag was not place on the bed during wound care. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 2 of 4 residents (Resident #10 and #11) reviewed for respiratory therapy in that: The facility failed to ensure Resident #10 and Resident 11's oxygen was set according to physician orders. This failure could place residents at risk of respiratory distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs to meet the needs for 1 of 9 Residents (#36) reviewed for pharmacy services in that: Register Nurse (RN) A failed to follow medication administration policies resulting in Licensed Vocational Nurse (LVN) A attempting to give Resident #36 a double dose of resident's 8:00 a.m. prescribed medications. RN A failed to document the start date for Resident #36's medications. Failures could place all residents at risk of drug diversion, health decline, and/or death.

Inspectors wroteBased on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster door was secured. This failure could place all residents at risk of infections, pests, and rodents from improperly disposed garbage.

Inspectors wroteBased on interviews and records reviewed, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 4 (Residents #92, #210, #212 and CR #93), of 8 residents reviewed for baseline care plans. -The facility failed to complete a baseline care plan within the required 48-hour timeframe for Residents #92, #210, #212, and CR #93. This failure could place residents at risk for not receiving necessary care and services or not having important care needs identified.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (LVN C) of 1 staff members reviewed for pharmacy services in that: LVN C stored Resident #44's Dorzolamide-Timolol 2-0.5% eye drops in the 2 [NAME] Medication cart uncapped. Resident #44s Dorzolamide-Timolol 2-0.5% eye drops was stored in the 2 [NAME] Medication cart without a cap while not in use. These failures could place residents receiving medications at risk for eye infections. Findings Include: Observation and interview on 5/10/2023 at 11:00 am revealed LVN C administering Dorzolamide-Timolol 2-0.5% eye drops to Resident #44's left and right eye. LVN C did not recap the eyedrop bottle. [...]

Inspectors wroteBased on observation, interview, and records reviewed, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen, reviewed for proper ice scoop storage in that: -The ice machine scoop was not stored in a covered container. This failure could place residents at risk for cross contamination and food-borne illness. Observation on 05/09/2023 at 3:45 p.m. revealed the ice machine scoop was being stored, uncovered, on the side of the ice machine. During an interview with the Dietary Manager on 05/09/2023 at 3:46 p.m., he said the ice scoop should be stored in an enclosed container. He said the container fell and broke last month. Record review of the facility's Ice Machines and Ice Storage revised date January 2012, read in part: Policy Statement: [...]

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage and refuse properly for 1 of 1 waste receptacle reviewed for garbage disposal. -The one dumpster contained waste and its two side doors were left open. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents.