Park Manor Of Westchase
Park Manor of Westchase in Houston, TX — inspection on February 22, 2025.
Found 1 citation. 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
What corrective actions have been implemented for the identified residents?
CR#1 is no longer a resident at the time of this plan of removal. No corrective action possible to be taken for CR#1.
How were other residents at risk to be affected by this deficient practice identified?
An audit of all residents who go out on pass within the last 30 days was conducted by the DON on 2/21/25 to ensure that adequate supervision and follow-up was completed for these residents. At the time of the audit, it was noted that there are fifteen residents who routinely go out on pass and no additional supervision or follow-up was required.
These residents were verified to be in-house by the DON on 2/21/25.
All residents who leave out on pass have the potential to be affected by this alleged deficient practice.
All residents who reside in the facility have the right to go out on pass and physician orders are not required to do so.
What does the facility need to change immediately to keep residents safe and ensure it does not happen again?
CR#1 is no longer a resident of the facility as of 2/21/25.
All nursing staff, including CNAs, CMAs and nurses to be in-serviced by DON/Designee on ensuring adequate supervision for residents who leave out on pass and do not return.
Additionally, they will be in-serviced on reviewing care plan interventions specific to residents going out on pass.
This will be completed by 2/21/25.
This includes notifying the administrator, DON and appropriate law enforcement agencies when a resident does not return from being out on pass.
What corrective actions were taken?
1.
The following actions were initiated immediately on 2/21/25.
a. On 2/21/25 an audit was completed by DON (Director of Nursing) to ascertain all residents who go out on pass to ensure that their care plans reflected as such.
The facility PPS nurse received this list from the DON and will update and revise all resident care plans for those who go out on pass.
This will be completed by end of business 2/21/2025.
b. DON and Administrator were educated on 2/21/25 by RVP (Regional [NAME] President of Operations) and CSD (Regional Clinical Services Director) on ensuring adequate supervision and follow up for residents who leave out on pass and do not return.
676059
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 676059 B.
Wing 02/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082