Every finding on record at Hca Houston Healthcare Southeast

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 of communicable diseases and infections, including handling and storing linens so as to prevent the spread of infection for 3 of 8 (Resident #17, Resident#137, Resident #123) residents reviewed for infection control. 1. The facility failed to ensure a a bag of linen was not left on the floor and untied in Resident #123's room on 5/13/2025. 2. The facility failed to ensure CNA T used proper infection control practices while using a Accu-Chek machine between Resident #137 and Resident #17 during blood glucose check. These failures could put residents at risk of developing and risk for cross contamination and infection. Findings included: 1. Record review of Resident #123's face sheet printed 05/14/2025, Resident #123 was an [AGE] year-old female who was originally admitted on [DATE]. Her medical diagnoses included acute right femur fracture, deep venous thrombosis (blood clot in a deep vein typically found in the lower body), urinary retention, hypertension (high blood pressure) and dementia. Record review of Resident #123's care plan dated 04/17/2025, who was documented as alert and oriented. She was care-planned for a history of falls with interventions including good lighting, use of wheelchair, fall risk band and socks, and increase in supervision. She was at risk of an infection due to UTI related to a Foley Catheter. She required two-person assists with her ADLS including bed mobility, transfers, walking and toileting. She required one-person assist with bathing and grooming/hygiene. She was incontinent of bladder and bowel and was care-planned for toileting every two hours and as needed and had an indwelling catheter and required peri-care (incontinent care). Record review of Resident #123's Annual MDS with a reference date of 04/23/2025, reflected had a BIMS score of 7, indicating severe cognitive impairment related to memory and thinking. Observation and interview on 5/13/2025 at 10:56am located in Resident #123's room revealed there was a large blue bag on the floor of the resident's bathroom, in front of the sink. RN F came into the restroom, picked up the bag and said it contained Resident #123's linens. RN F also said the bag should not be on the floor and did not know who left the bag on the floor and that someone should have taken it downstairs when Resident #123 went down for therapy. RN F placed gloves on her hands, tied up the bag and said she was going to dispose of it. RN F said the opened bag posed no risk to the resident because RN F knew Resident #123 was not mobile and that she had family there to help her, but that the open linen bag should not have been there. When asked if there were any other risks, she re-stated that there were no risks, but the bag should not have been there. Interview on 5/13/2025 at 2:09pm with CNA K, who said that she did not know who placed the blue bag in Resident #123's room, but if she saw the bag she would tie it and take it down to be washed. CNA K said leaving the opened bag on the floor could lead to infection control issues. Record review of the facility's policy on Infection Control last revised 05/2025 read in part, the duties and responsibilities of the facility's Infection Control Committee included reviewing Infection Control policies and instituting appropriate control measures and C. Surveillance 1. Activities to prevent and control infections in: patients, licensed independent practitioners, staff, volunteers, students and visitors are included in surveillance. 2. Record review of an undated Face Sheet for Resident #137 reflected she was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy. The pancreas (gland) does not make enough insulin to carry sugar into cells to fuel the body), essential (primary) hypertension (high blood pressure) osteomyelitis (infection in a bone) needs for assistance with personal care, and amputation. Record review of an annual MDS dated [DATE], for Resident #137 reflected she had a BIMS score of 15 indicating intact cognitive status. Record review of an undated Face Sheet for Resident #17 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy. The pancreas (gland) does not make enough insulin to carry sugar into cells to fuel the body), essential (primary) hypertension (high blood pressure) During observation on 5/13/25 at 11:47 AM of CNA T performing accu check to Resident #137, C.NA T was using a accu check needle, stuck Resident #137 middle finger, squeezed blood drop on the lancet in the accu check machine and read the blood glucose. CNA T did not clean the glucometer machine before and after checking Resident #137 blood glucose. CNA T then went to Resident #17, checked blood glucose, and took the glucometer machine and placed it on the base machine at the nurse's station. Interview with CNA T on 5/13/25 at 12:05 PM regarding not cleaning the accu check machine in between Resident's #137 and Resident #17 and taking the Glucometer to the nurse's station. CNA T said she did change her gloves and use hand sanitizer. CNA T said she had in-services about accu check machine and obtaining blood glucose CNA T was asked to find out from her trainer what she did not do during the process. CNA T said the nurse who trained her no longer work for the hospital . Interview with CNA T on at 12:40 PM on 5/13/25 CNA T stated, I apologize, she was supposed to clean accu check machine in-between residents to prevent cross contamination. Interview with ACNO and CNO on 5/14/25 at 4:30 AM regarding accu check machine not being cleaned in-between resident after checking their blood glucose. ACNO said the staff was supposed to disinfect the machine between residents to prevent infection. Record review of facility policy dated revised 05/2025: Infection control program/plan skilled nursing unit reflected the following: DEVELOPMENT OF GOALS A. The hospital establishes priorities and sets goals for preventing the development of health care-associated infections with in the hospital based on risk identified in the Infection Control Risk Assessment (IC.01.03.01). In order to continue the hospital's excellence in patient care, the following infection control goals have been established: 1. To identify and reduce the risks of acquiring and transmitting infections among patients, employees, physicians, other licensed independent practitioners, contract service workers, volunteers, students, and visitors by pursuing sound infection control practices such as standard precautions, aseptic technique, and other isolation as needed and appropriate. 2. To limit unprotected exposure to pathogens

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety observed for 2 of 3 (Fridge and Freezer) food storage locations observed. -thereon 05/13/2025, there were no dates indicating when items in the kitchen was opened, delivered or when it could be expired and included one box of green onions that was in a box located in the fridge with no date on it. There was one opened bag of potato fries and one opened bag of chicken strips located in in the freezer with no date opened recorded on them. This failure could put residents at a nutritional risk of eating food past their expired or best by date. Findings included: Observation and interview on 5/13/2025 at starting at 8:10 am in the facility's food storage rooms revealed in the fridge there was a box of green onions in a cardboard container filled to the top with no date written on it. The DM said that the electronic system would be able to tell her through the code on the box of when items were expired, and she did not know why the box of green onions was not labelled or why there were no dates indicating when it was opened or delivered or when it could be expired, and she would look into it. In the freezer there were two opened bags of food tied up, one with potato fries and the other with chicken strips. The DM said those needed to be labelled with the open date and she would start that process to educate her staff on labelling it. A later interview on 5/13/2025 at 1:35pm, the DM said she sent the policies on food labelling to the Administrator. Interview on 5/14/2025 at 3:16 pm with the ACNO and Administrator, the Administrator said that if food was not labelled properly, it could go bad and then the facility would be serving something not fresh and that items like the potato fries and chicken strips were left out without labelling, the facility would not know if the food items were good to be served to residents or not. Request for review of the food labelling policy was sent by email to the DON and Administrator on 5/14/2025 at 8:36 am. The same email was forwarded to the ACNO on 5/14/2025 at 9:14am, and the ACNO was also asked about reviewing the policy for food storage and the ACNO came to the room at that time and verbally responded that she would look into it and send it. The policy was not received prior to exit on 05/15/2025.

Based on interview and record review, the facility failed to develop and implement polices for annual screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse for 6 of 11 staff (DON, RN A, RN B, Social Worker, LVN A, and CNA C) reviewed for annual abuse screenings. The facility failed on 05/15/2025 to annually conduct a search of the NAR (Nurse Aide Registry) and EMR (Employee Misconduct Registry, used to check if unlicensed staff have committed any acts of abuse, neglect or misconduct and prevent employing them) registry for all employees every twelve months after the initial hire date and keep a copy of the annual search results in the facility's personnel file for DON, RN A, RN B, Social Worker, LVN A, and CNA C verifying staff's employability. The failure could place residents at risk of being abused, neglected, or exploited by unemployable staff. Findings included: Interview and record review with the ACNO and HR VP on 5/15/2025 beginning at 8:46 am, the HR VP said that staff had background checks conducted upon hire or when moved to a different position. HR VP verified the following background checks for staff were completed through the facility's online HR portal: DON had background check on 3/11/24 and was employable, RN A had a background check on 7/14/2022 and was employable, RN B had a background check on 4/27/2023 and was employable, the Social Worker had a background check on 10/19/2015 and was employable, LVN A had a background check on 06/23/2023 and was employable, and CNA C had a background check on 8/29/2023 and was employable. These were the only dates made available as of exit -5/15/2025.The HR VP said the facility's policies did not include annual employee misconduct checks, but she would talk to corporate staff about it. A later interview with the ACNO and the HR VP on 5/15/2025 at 2:26 pm, the HR VP said she went ahead and did misconduct registry checks on all staff. The HR VP said that the facility gets monthly background check updates through OIG, which was how they (the facility) ensured staff were employable and able to work with residents. Interview on 5/15/2025 at 3:33pm with the ACNO, CNO, the HR VP and Administrator, the ACNO said that the purpose of background checks were to make sure staff have not committed any offenses anywhere including at other facilities and to avoid the risk of resident abuse. The CNO said background checks ensured staff were in good condition and not putting residents at risk of abuse. The HR VP said she would be talking to corporate staff about implementing the process to ensure misconduct checks were done annually going forward. Review of the OIG monthly record checks and the most recent misconduct registry checks were requested from the HR VP and was not received prior to exit on 05/15/2025. Record review of the facility's policy on Preventing Patient Abuse last revised 04/2024 read in part, Our abuse prevention/intervention program includes, but it's not necessarily limited to, the following: This Community i. Conducting background investigations to prevent hiring persons who have been found guilty (by a court of law) of abusing, neglecting, or mistreating individuals or who have had a finding of such action entered into the nurse aide registry . This community will conduct employment background screening checks and criminal conviction checks on persons making application for employment within this community.

Based on observation, interview and record review, the facility failed to ensure personal privacy including medical treatment, personal care and visits for 2 of 8 (Residents #123 and #128) reviewed for personal privacy. 1.Resident #123 was observed receiving medical treatment on 5/13/2025 and 5/15/2025 with Resident #123's room door open and no privacy curtain pulled. 2.Resident #128 was receiving incontinent care when her physician entered her room without knocking or introducing themselves. This failure could cause residents to feel loss of dignity and respect and affect their emotional well-being by not ensuring they have total privacy while receiving care. Findings included: 1. Record review of Resident #123's face sheet printed 05/14/2025, Resident #123 was an [AGE] year-old male who was originally admitted on [DATE]. His medical diagnoses included hypertension, foot ulcer infection, functional quadriplegia (paralysis of all limbs), morbid obesity and deep vein thrombosis (when you have a blood clot that forms in a vein deep in your body, typically lower leg, thigh or pelvis). Record review of Resident #123's care plan dated 05/06/2025, he was documented as alert and oriented. He was dependent on staff for bed mobility, transfer, walking, toileting, bathing and grooming/hygiene. Record review of Resident #123's MDS (a comprehensive resident assessment) with a reference date of 05/12/2025, he had a BIMS score of 10, indicating moderate cognitive impairment related to memory and thinking (skills such as problem-solving). Observation of Resident #123 on 5/13/2025 at 10:05am, who was receiving care from a staff member and what sounded like suctioning. Resident #123's door was open, and the privacy curtain was not pulled. A later observation and interview with Resident #123 on 5/15/2025 at 3:17pm, who was observed with his door open. Resident #123 was in bed with the PL next to Resident #123 tying an orange tourniquet around his left arm. The PL stated she was a staff member, and she was Resident #123's phlebotomist. The PL said his door was open because she needed help and was waiting for someone to come in but that the door should be closed. The PL then called a nurse to assist her then turned around and closed Resident #123's door. Observation and interview on 5/15/2025 at 3:17pm with Resident #123 and their FM, Resident #123 was sitting in a chair in his room eating and appeared comfortable and relaxed with no discomfort noted. Resident #123 said he did not mind that his room door was open while the phlebotomist was in the room performing a procedure. Resident #123 said if Resident #123 was just getting his blood drawn it was okay since it was not a serious or vulnerable procedure. 2. Record review of Resident #128's face sheet printed 05/14/2025, Resident #128 was an [AGE] year-old female who was originally admitted on [DATE]. Her medical diagnoses included hypotension (low blood pressure, multiple falls, right hip fracture, urine retention, indwelling catheter, pain and edema of extremities. Record review of Resident #128's MDS with a reference date of 04/26/2025, he had a BIMS score of 07, indicating moderate cognitive impairment related to memory and thinking. Record review of Resident #128's care plan dated 04/26/2025, he was documented as alert and oriented. She was dependent on staff for bed mobility, transfer, walking, toileting, bathing, indwelling catheter and grooming/hygiene. Observation and interview on 5/15/2025 at 3:22pm with Resident #128 and their FM, Resident #128 was lying in bed with her head slightly elevated and appeared comfortable and in a pleasant mood with no discomfort noted. Resident #128 said the MD never introduced himself since being her doctor. The FM said the MD walked into the room while Resident #128 was getting incontinent care 5/14/2025 and did not knock or introduce himself to Resident #128. The FM said the MD would often walk into Resident #128's room and talk to the FM and not acknowledge Resident #128. When asked how the MD walking into the room and not talking to her made her feel, Resident #128 shook her head and said it's only right that the MD introduces himself to the resident and that she would like the doctor to talk to her. Interview on 5/15/25 at 3:17PM with Resident #128 and FM, FM said that that doctor never introduces himself since Resident #128 was at the facility. Resident #128 said I have an old butt so it's not like it's anything to look at, meaning she considered heself older and possibly less attractive to doctor, but she would prefer he introduce himself and acknowledge and talk to Resident #128. FM said doctor would walk in and talk to her and not look at the resident and FM told resident she should tell the doctor that. It's only right that he introduces himself, said the resident. Record review of the facility's policy on Resident Rights last revised 08/2025 read in part, Resident Rights include: . 4. To be treated with courtesy, consideration, and respect .6. To privacy, including privacy during visits and telephone calls.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bowel and bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #128) reviewed for incontinence care. When C.NA K was providing incontinent care to Resident # 128 on 05/14/2025, CNA-K did not separate the resident's llabia, did not clean the base of her labia or clean the indwelling Foley catheter ( is a thin, flexible tube place through the urethra to carry urine from the bladder) and failed to maintain Resident #128's drainage bag below the level of the bladder. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #128's face sheet printed 05/14/2025, Resident #128 was an [AGE] year-old female who was originally admitted on [DATE]. Her medical diagnoses included hypotension (low blood pressure, multiple falls, right hip fracture, urine retention, indwelling catheter, pain and edema of extremities. Record review of Resident #128's MDS with a reference date of 04/26/2025, he had a BIMS score of 07, indicating moderate cognitive impairment related to memory and thinking. Record review of Resident #128's care plan dated 04/26/2025, reflected Resident #128 was documented as alert and oriented. She was dependent on staff for bed mobility, transfer, walking, toileting, bathing, indwelling catheter and grooming/hygiene. Observation on 05/14/2025 at 2:53 PM for incontinent/indwelling catheter, with RN F assisting C.NA K, CNA-K cleaned Resident #128's left and right groin area, then just cleaned the middle one of the resident's genital areas without separating the resident's labia area. Further observation revealed CNA-K did not cleaned the indwelling catheter, then RN F and C.NA K turned resident to her right side., C.NA K then picked up indwelling bag with 300 cc of urine and placed it on the bed, she cleaned in-between the resident's bottom with, small bowel movement, then put a new and clean brief on the resident and and closed it. Interview with RN F on 5/14/25 at 3:03 PM said CNA K did not clean indwelling catheter and she confirmed that CNA K placed urine bag with 300 cc of urine on the bed. RN F said CNA K should not do place urine bag on the bed because the urine could back flow to the bladder and cause infection. Interview with CNA K on 5/14/25 at 3:08 PM who said she did a good job, when asked if the F/C should be place on the bed, she said she was trying to avoid pulling from catheter that would hurt the resident. CNA K, said she forgot to clean the catheter, knew not cleaning the catheter could cause infection and not cleaning the buttocks could cause skin break down, . Further interview with CNA-K said she forgot to separate the resident's labia area to clean the base of labia and indwelling catheter because she was so nervous. CNA K said she started working with facility since 1/2025 and she had in-service on incontinent and catheter care. Interview with ACNO and CNO on 5/14/25 at 4:30 PM regarding the incontinent and F/C care, they both stated that indwelling catheter should not be place on the bed to prevent urine back flow and UTI. ACNO said they would do in-service to the staffs. Record review of facility policy dated revised 10/2024: Urinary device policy .D. Drainage Bag Maintenance and emptying. Reflected the following:,. 2. Keep the drainage bag below the level of the bladder.