The Sarah Roberts French Home

Inspectors wroteBased on interviews, record review the facility failed to at the time each resident is admitted , the facility must have physician orders for the resident's immediate care for 1 of 8 (2) residents in that:Resident #2 did not have an order to be admitted to the facility. This could affect all new resident admission and could delay care.

Inspectors wroteBased on interviews, record review the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter for 1 of 8 (Resident #2) residents that required physician visits in that: Resident #2 was not seen by a physician within the first 90 days after admission. This could affect all new admissions and could result in a delay in care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were provided pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 Residents (Resident #7) reviewed for medication administration. LVN C administered a whole pill medication to Resident #7 who required her medications to be crushed. This Failure could place residents at risk for not receiving the intended therapeutic effects of their prescribed medications.

Inspectors wroteBased on observation, interview, and record review, 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 diseases and infections for 1 of 1 resident (Resident #1) reviewed for infection control. The facility failed to ensure CNA A and CNA B utilized proper PPE while providing care for Resident #1. This failure could place residents at risk of infection or illness.

Inspectors wroteBased on observation, interview and record review the facility failed to, ensure that all alleged violations involving abuse, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 4 of 5 Residents (Resident #1, Resident #2, Resident #3 and Resident #4) whose records were reviewed. 1. The facility failed to report a fracture of Resident #1's coccyx/geal on 12/28/24, the date they received report from Hospice of the X-ray results. The facility made the report to HHSC on 12/30/24. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 17 (Cook A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, Admin, DON, ADON) of 17 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to [NAME] A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, Admin, DON, ADON annually. The facility failed to ensure required trainings were provided to the Admin upon hire. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 17 (Cook A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, Admin, DON, ADON) of 17 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to [NAME] A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, Admin, DON, ADON annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on behavioral health for 16 of 17 employees (Cook A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, DON, ADON) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided [NAME] A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, DON, ADON annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on communications training for 8 of 17 employees (Cook A, Maintenance, CNA E, Med Aide D, CNA F, [NAME] B, LVN G, LVN I) reviewed for training, in that: The facility failed to ensure effective communication training was provided to [NAME] A, Maintenance, CNA E, Med Aide D, CNA F, [NAME] B, LVN G, LVN I annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on rights of the resident training for 3 of 17 employees (Cook A, Admissions, DON) reviewed for training, in that: The facility failed to ensure effective rights of the resident training was provided to [NAME] A, Admissions, DON annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

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 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

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 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged while the appeal was pending for 1 of 5 residents (Resident #1) reviewed for discharges, in that: The facility failed to have a valid reason to discharge Resident #1 and failed to permit Resident #1 to remain in the facility while her discharge appeal was pending. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/22/23 at 5:01 p.m. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 5 residents (Resident #1) reviewed for discharge rights, in that: The facility failed to ensure Resident #1 had a safe and orderly discharge to a home environment on 9/19/23. During or after the discharge, Resident #1 broke her leg and was hospitalized . This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/22/23 at 5:01 p.m. While the IJ was removed on 9/24/23 at 7:06 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were discharged safely. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.