Ignite Medical Resort Sugar Land, LLC

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan area for Resident #1's use of a midline to receive IV antibiotics. This failure placed residents at risk for inconsistent care, complications related to midline catheter, and a decline in health status.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to provide reasonable accommodations to meet the needs of 2 (Residents #1 and #2) out of 8 residents reviewed for call lights. The facility failed to ensure a call light system was available for Resident #1. The facility failed to ensure a call light was within reach for Resident #2. This failure has the potential to put residents at risk of not having their needs met when they are unable to contact staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and contained. B. Ensure general cleanliness was maintained. C. Ensure substitution list, cleaning list and temperature logs were utilized. These failures could place all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of six residents reviewed (Resident #18) for pressure ulcers. 1. The facility failed to ensure Resident #18 received services and treatment orders to prevent sacral pressure ulcers from healing. These failures could place residents at risk for worsening of existing wounds or development of new pressure ulcers.

Inspectors wroteincontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #18) reviewed for incontinent care. 1. The facility failed to ensure CNA A separated Resident #18's labia, cleaned the foley catheter insertion site and performed proper hand hygiene during foley care for Resident #18. 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 residents who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for tracheotomy care (Resident #5). The facility failed to ensure RN R used sterile technique during tracheotomy care and suctioning for Resident #5. These failures could place residents with a tracheotomy requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #177) reviewed for pharmacy services. LVN A failed to administer Lacosamide (medicine used to treat seizures), and Hydralazine (medicine used to lower blood pressure); to Resident #177 at 7:00am as ordered by the physician. LVN A failed to administer the whole dose of Hydralazine and Carvedilol (medicines used to lower blood pressure); Baclofen (medicine used as skeletal muscle relaxants); Glycopyrrolate (treats chronic obstructive pulmonary disease); Doxycycline (medicine used bacterial infections); and Isosorbide (medicine used to treat uncontrolled arterial hypertension) to Resident #177 as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of five percent (%) or greater. The facility had a medication error rate of 26% based on 8 errors out of 30 opportunities, which involved 1 of 5 residents (Resident #177) reviewed for medication errors. LVN A administered Lacosamide (medicine used to treat seizures), and Hydralazine (medicine used to lower blood pressure); to Resident #177 at 9:08am instead of 7:00am as ordered by the physician. LVN A administered the wrong dose of Hydralazine and Carvedilol (medicines used to lower blood pressure); Baclofen (medicine used as skeletal muscle relaxants); Glycopyrrolate (treats chronic obstructive pulmonary disease); Doxycycline (medicine used bacterial infections); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster floor were free of debris. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 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 disease and infection for 2 of 5 residents (Resident #18) reviewed for infection control, in that: CNA A did not change her gloves or wash her hands after providing incontinent care to Resident #18. RN R did not change her gloves or wash her hands during pressure ulcer treatment and after providing treatment to Resident #18 RN R did not change her gloves or wash her hands and used sterile technique during tracheotomy care and suctioning for Resident #5. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 to 7 residents (CR#1) reviewed for CPR. -RT A and LVN A failed to initiate life-saving measures (CPR) when CR#1 who had a full code (meaning all resuscitation procedures provided if their heart stops beating or stop breathing) immediately when she was found unresponsive and died. -The facility failed to ensure that CR #1 received Cardio-pulmonary resuscitation (CPR) in accordance with professional standards of practice. -The facility failed to immediately initiate CPR when CR#1 was found unresponsive at or about 5:25 a.m. EMS was called at 5:37 a.m. A delay of 12 minutes initiating CPR. An Immediate Jeopardy (IJ) was identified on [DATE]. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that residents who needs respiratory care is provided such care consistent with professional standards, the comprehensive care plan, the residents goals, and preferences for 1 of 5 (CR#1) residents reviewed for respiratory and tracheostomy care in that: -The facility failed to ensure that CR#1 who needed respiratory care, including tracheotomy care circuit was attached appropriately causing it to become dislodged resulting in agonal breathing, cardiac arrest, and death. -The facility failed to have emergency tracheostomy equipment at CR#1's bedside when CR#1 trach dislodged. An Immediate Jeopardy (IJ) was identified on [DATE] at 05:42pm . The IJ template was provided to the facility on [DATE] at 5:42pm. [...]

Inspectors wroteBased on observation interview and record reviews the facility failed to provide pharmaceutical services including procedure that assure accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 (Resident #8) residents reviewed for pharmaceutical services. -Facility failed to implement effective pharmaceutical procedures when RN A incorrectly added an order to Resident #8 to administer 12 units of Lispro insulin subcutaneously every 8 hours. Resident #8 who was not diabetic caused himcaused him to sweat and become lethargic and had to be sent to the emergency room due to hypoglycemia (low blood sugar). -The facility failed to prevent Resident #8 from receiving 48 units of insulin within 24-hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #7) reviewed for medications received the appropriate treatment and services to prevent complications of enteral feeding/medication administration including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities. -The nurse failed to verify placement of Resident #7's G-tube prior to administering medications. This failure could place residents at risk for complications from medications not entering the stomach.