Focused Care At Beechnut
Focused Care at Beechnut in Houston, TX — inspection on July 2, 2024.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reporting changes in condition to the ADON, the DON, and the MD, including missed appointments.
jeopardy to resident health or Interview with LVN N on 07/02/2024 at 2:08PM, he was in-serviced on scheduling and documenting safety appointments.
appointments and notifying the MD and the DON with changes in condition.
In an interview with LVN B on 07/02/2024 at 1:38PM, she was in-serviced on scheduling and following up with residents' appointments and notifying physicians with changes in condition.
In an interview with RN C on 07/02/2024, she said she was in-serviced regarding documenting, confirming, and following up with appointments.
Record review of in-services, all staff completed the following: Record review of policies/procedures, in-services provided 6/28/2024 to 7/2/2024 Policy: Skin Management: Prevention and Treatment of Wounds Effective: 11/01/2019 Last Revised: 10/06/2022 Catheter Policy: Indwelling, straight, Supra-Pubic and external, dated effective 4/20/2021.
Social Worker/Designee in-service on documentation of appointments.
Pain Assessment.
Department Head, Nurse Management Appointment In-service.
Wound Care Nurse Competencies.
Wound Care one on one-disciplinary action form.
Cath and Foley Care/securing catheter, skin assessment.
The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/02/2024 at 3:45PM.
The facility remained out of compliance at a severity level of 2 and a scope of E due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
675000 07/02/2024
Focused Care at Beechnut 12777 Beechnut St Houston, TX 77072
into place.
jeopardy to resident health or Resident #54 safety Record review of Resident #54's face sheet dated 06/27/24 revealed he was a [AGE] year-old male
which included: diabetes mellitus (body do not produce enough insulin or cannot use it properly), hypertension (high or raised blood pressure), urinary tract infection (an illness in any part of the urinary tract), and neuromuscular dysfunction of the bladder (the nerves and muscles do not work together very well).
Record review of Resident #54's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 of 15 indicated moderate impaired cognition.
Further review revealed the resident had indwelling Foley.
Record review of Resident #5[TRUNCATED]
675000 07/02/2024
Focused Care at Beechnut 12777 Beechnut St Houston, TX 77072
During an observation and interview on 06/26/24 at 1:34 p.m., the Administrator said he could see the hand-washing soap broken.
The Administrator said the laundry aide should not go to the restroom to wash her hands because it was an infection control issue.
The Administrator stated LS A left one area to another area to wash her dirty hands, and she could have transferred the germs to the area where she went and washed her hands.
The Administrator said LS A could have contaminated her hands on her way back to the clean area in the laundry room and could have transferred the germs to the clean linens, which was an infection control issue.
The Administrator said clean linens should not be stored in dirty areas, and no clothes should be on the floor or staff personal items on the clean table for clean linen for infection control reasons.
Record review of the facility policy on laundry and bedding, soiled dated 2001 MED-PASS, Inc. (Revised October 2018) read in part . soiled laundry/bedding shall be handled, .processed according to best practices for infection prevention and control .transport #6 . clean linens are stored separately, away from soiled linens, at all times .
The facility failed to assess, follow-up with treatment, update the care-plan, obtain new order due to a change in resident # 72's skin condition of the groin and resident's report of pain, at which time the penis split measured 8 cm length by 1 cm width by .4 cm depth and appeared red and raw, and failed to ensure that Resident #72's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter.
2.
The facility failed to ensure that CNA B changed her gloves and perform hand hygiene while providing indwelling catheter and incontinent care to Resident #72.
On 6/28/24 at 5:44PM an Immediate Jeopardy (IJ) was identified.
While the IJ was removed on 6/30/2024 at 12:27 pm, the facility remained out of compliance at a scope of isolated and a severity of harm with potential for more than the minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.
3.
The facility failed to ensure CNA G and CNA H did not place foley bag on Resident #54's bed during foley and incontinent care.
These failures could affect residents in delay of appropriate medical treatment leading to pain, discomfort, and death.
Findings included:
Resident #72
Record review of a facility face sheet dated 6/26/2024 indicated Resident # 72 was a [AGE] year-old male and admitted on [DATE] and was readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis), obstructive and reflux uropathy (the urine backs
up into the kidney and cannot drain through the urinary tract), chronic kidney disease, major depressive disorder, neurogenic bladder (nerves that communicate between the bladder and spinal cord and brain malfunction and cause symptoms such as dribbling urine, loss of feeling the bladder is full and being unable to control urine), muscle wasting and atrophy (wasting away of tissue or organ).
Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #72 had a BIMS score of 09 indicating moderately impaired cognition, and he required an indwelling catheter.
675000
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 675000 B.
Wing 07/02/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Beechnut 12777 Beechnut St Houston, TX 77072
The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following:
Observation and interview on 6/30/2024 at 11:00 am with Resident #72 was sitting in wheelchair eating a snack. He was well-groomed with no odors. Resident #72 said he is feeling okay but wondered why it took the facility so long to address his catheter. He said he was now afraid of an infection from his stoma to g-tube. Resident #72 raised his shirt at that time and a small pea-sized area was observed in what appeared to be a white cream. Resident #72 consented for the DON to come assess him with another staff member. He was then transported back to his room.
The DON later came and said that the white substance was not an infection but a cream that they used to treat the stoma called theravox, which was confirmed by viewing the container and conducting a record review of Resident #72's physician orders.
In an interview on 6/29/2024 at 10: 20 AM RN A said she had been working with the facility for 8 months 6:00 AM to 6:00 PM shift.
She had in-services on incontinent care, indwelling catheter care, securing catheter, hanging foley bag below the bladder, and reporting any abnormalities to the charge nurse like skin irritation. If there were any changes in the site notify the NP and check indwelling catheter every shift.
They were assessing catheter before daily but now every shift and for any slit to the penis they should document in the progress note.
In an interview on 6/29/2024 at 10: 49 AM LVN A said she had been working with the facility for 1 year on the 6:00 AM to 2:00 PM shift.
She had in-services on incontinent care, indwelling catheter placement, securing the catheter, and reporting any abnormalities to the doctor like skin irritation and document.
675000
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 675000 B.
Wing 07/02/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Beechnut 12777 Beechnut St Houston, TX 77072
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.