La Bahia Nursing & Rehabilitation

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a medication error rate was not 5 percent or greater. The facility had a medication error rate of 17.65%, based on 6 errors out of 34 opportunities, which involved 3 of 6 residents (Residents #5, #25 and #43) and 1 of 4 staff (DON) reviewed for medication administration reviewed for medications errors. The facility failed to ensure the DON administered medications to Residents #5, #25 and #43 timely and according to physician order. This deficient practice could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.

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 3 of 8 residents (Residents #10, #22 and #36) and 1 of 1 facility (the facility) reviewed for infection prevention and control measures. 1. The facility failed to ensure CNA C cleaned the urinary collection tube from Resident #10s indwelling catheter.2. The facility failed to ensure CNA C did not place Resident #10's urinary collection bag on the bed and on the floor.3. The facility failed to ensure CNA B followed infection control protocols while delivering Resident #22 and Resident #36's lunch meals. 4. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure within 14 days after a facility completed a resident's assessment, the facility electronically transmitted encoded, accurate, and complete MDS data to the CMS System upon a resident's transfer, reentry, discharge, and death, for 1 of 8 residents (Resident #4) reviewed for transmitted MDS data to the CMS System. The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #4. This deficient practice could place residents at risk of MDS inaccuracies. Record review of Resident #4's admission Record dated [DATE] documented a [AGE] year-old male who was originally admitted to the facility [DATE] and most recently admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and was developed within 48 hours of a resident's admission for 1 of 8 residents (Resident #10 reviewed for baseline care plans. 1. The facility failed to ensure Resident #10's baseline care plan reflected the residents immediate need for support with an indwelling urinary catheter.2. The facility failed to ensure Resident #10's baseline care plan was developed within 48 hours of admission. These failures could place residents at risk of a decline in health status.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's prescribed diet for a regular diet texture with finger foods and ground textured meats, were reflected in the residents care plan. This failure could place residents at risk for a decline in their health status.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 8 residents (Resident #10) reviewed for urinary catheter care. The facility failed to ensure CNA C performed urinary catheter care for Resident #10 according to professional standards. This failure could place residents at risk for a decline in health status.

Inspectors wroteBased on Observations, Interviews, and Record review, the facility failed to ensure that residents had 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 1 of 3 residents (Resident #22) reviewed for reasonable accommodation of resident needs and preferences, in that: The facility failed to ensure Resident #22's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 garbage dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. 1. The facility failed to ensure garbage dumpster #1's lid was completely shut. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings inclulded: 1. Observation on 11/7/24 at 11:05am with the Dietary Director revealed that one of two garbage dumpsters (dumpster #1) had a 3 x 5 foot lid that was completely open exposing the garbage inside of the dumpster. During an interview on 11/7/24 at 11:10 a.m., with the Dietary Director she stated that having an open lid to the garbage dumpster would allow pests access to the garbage and possibly the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-for 1 of 11 residents (Resident #2) reviewed for care plans, in that: The facility failed to ensure Resident #2's care plan was revised with updated interventions to address 4 of 6 actual falls (01/10/2024, 01/20/2024, 01/29/2024 and 02/08/2024) documented on incident reports and nursing notes. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 16 residents (Resident #1) reviewed for accident hazards and supervision, in that: On [DATE] CNA A inappropriately transferred Resident #1 with a mechanical lift by herself, which caused a fall resulting in back pain from the mechanical lift support bar hitting her head and landing on the floor. The non-compliance was identified as PNC which began on [DATE] and ended on [DATE]. The facility had corrected the non-compliance before the survey began. This failure could result in residents requiring transfer by a mechanical lift suffering injury, a diminished quality of life, and/or death.

Inspectors wroteBased 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 4 Residents (Resident #1) whose records were reviewed for abuse and neglect., in that; The facility failed to report to the state reporting agency (HHSC) an injury of unknown origin when Resident #1 suffered a change of condition and the hospital reported bleeding in the brain and a back fracture. This deficient practice could affect any resident and could contribute to further abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 3 of 26 staff (CNA E, Hskg F, LVN G) reviewed for abuse and neglect, in that: The facility failed to implement their abuse policy when a criminal background check and the EMR was not completed prior to their hire dates for CNA E, Hskg F and LVN G. These deficient practices could place residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to conduct a performance review at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 5 of 7 CNA's (CNA B, CNA C, CNA D, CNA H and CNA J) reviewed for performance reviews, in that: The facility failed to conduct performance reviews at least every 12 months for CNA B, CNA C, CNA D, CNA H and CNA J This failure could result in residents not receiving the necessary care and services due to nurse aides not receiving training based on their performance review outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 1 medication room reviewed for storage, in that: Controlled medications were not kept in a separate, permanently affixed compartment in the medication room. This deficient practice could place residents at risk of misappropriation of medications.

Inspectors wroteBased on observations, interviews and record reviews failed to accommodate residents' food preferences for 1 of 17 (Resident #28) residents reviewed in that: The facility failed to ensure Resident #28 received her preference of a lettuce and tomato salad during the lunch meal on 10/03/2023 and her preference of an over easy egg. This failure could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: 1. The facility failed to ensure items in the walk-in refrigerator and dry storage areas were dated and or discarded correctly. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 resident (Resident #17) reviewed for privacy, in that: CNA A and CNA B did not completely close Resident #17's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased 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 for 1 of 2 resident (Resident #15) reviewed for incontinent care, in that: While providing incontinent care for Resident #15, CNA C did not clean between Resident #16's buttocks'' cheeks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

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 infection for 1 of 5 residents (Resident #15) reviewed for infection control, in that: CNA D failed to perform hand hygiene or change her gloves after touching the soiled briefs and before touching the clean briefs. This deficient practice could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 1 of 20 employees (OT Q) reviewed for training, in that: The facility failed to ensure OT Q completed effective communication training. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 2 of 20 employees (CNA D and CNA J) reviewed for training, in that: The facility failed to ensure CNA D and CNA J completed QAPI training since their hired date. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 2 of 20 employees (CNA I and LVN O) reviewed for training, in that: The facility failed to ensure CNA I and LVN O completed behavioral health training since their hired date. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.