Spindletop Hill Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Spindletop Hill Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF610Feb 7, 2025

  Based on interview and record review, the facility failed to thoroughly investigate and have evidence that all alleged violations were thoroughly investigated and/or prevent further potential abuse for 2 of 2 residents (Residents #1 and #2) reviewed for allegations of abuse or neglect. The facility failed to conduct a thorough investigation when Resident #1 alleged CNA A wanted to be intimate approximately in October 2024. The facility failed to conduct a thorough investigation when an unknown staff alleged CNA B caused Resident #2 injury during care November 26, 2024. An Immediate Jeopardy (IJ) was identified on 02/06/25. The IJ Template was provided to the facility on [DATE] at 11:48 a.m. […]

• Immediate jeopardy, patternF580May 14, 2021

  Based on observation, interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 2 of 3 residents reviewed for notification of changes. (Residents #3 and #6) After podiatrist saw Resident #3 and indicated a wound consult was needed, the facility failed to schedule the wound consult or consult with Resident #3's physician. The resident was transferred to the ER 9 days later and diagnosed with [CONDITION(S)] (infection of the bone). Resident #3's great toe was amputated while in the hospital. The facility failed to consult physician when Resident #6 developed an open wound on her coccyx. An Immediate Jeopardy (IJ) situation was identified on 5/12/21. […]

• Immediate jeopardy, patternF686May 14, 2021

  Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable was provided for 2 of 3 residents reviewed for pressure injuries. (Resident #s 3 and 6) The facility did not: * Assess, consult the facility physician (for five days), get a wound care consult as ordered, or provide wound care (for 9 days) for Resident #3's left bunion (joint at the base of the big toe) pressure injury found by the facility consultant podiatrist on 4/28/21. The resident was admitted to the hospital on 5/7/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF760Jul 30, 2025

  Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication errors. On 07/24/25 LVN A administered 8 units of insulin outside of parameters (hold for BG less than 100). LVN B noted a change of condition for Resident #1 on 07/24/25. She was unable to rouse, clammy, and lethargic and only responded to painful stimuli. Resident #1 was admitted to hospital for hypoglycemia. The facility did not identify this significant medication error. An IJ was identified on 07/29/25. The IJ template was provided to the facility on [DATE] at 1:18 p.m. […]

• Immediate jeopardy, isolatedF609Feb 7, 2025

  Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator or HHSC and failed to ensure that all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or neglect resulting in serious bodily injury, to the State Survey Agency, 2 of 2 residents (Residents #1 and #2) reviewed for reporting allegations of abuse or neglect. 1. The SW did not report to Administrator D that Resident #1 made an allegation in approximately October 2024 that CNA A wanted to be intimate with her. […]