West Janisch Health Care Center
West Janisch Health Care Center in Houston, TX — inspection on October 7, 2025.
Found 6 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
jeopardy to resident health or safety
partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort.
Sit to stand: Resident's usual performance is dependent the effort.
Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity.
Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20
Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder.
Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities.
Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet.
Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary.
Transfer: supervision by staff to move between surfaces Resident #25 Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure.
Depression, dependence on dialysis, and dementia.
The resident discharged to the hospital on [DATE].
Record review of Resident #25's Discharge MDS dated [DATE] revealed, Modified independence.
Cognitive skills for daily decision making and set up or clean up assistance with most ADL's. As well as partial to moderate assistance with most functional abilities.
Record review of Resident #25's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues,setup, and/or assistance with ADLs r/t dx dementia, anxiety, depression; Interventions- Chair/bed-to-chair transfer: resident's usual independent - resident completes the activity with no assistance from a helper.
Lying to sitting on side of bed- resident's usual independent - resident completes the activity with no assistance from a helper.
Roll left and rightresident's usual independent - resident completes the activity with no assistance from a helper.
Sit to lyingresident's usual independent - resident completes the activity with no assistance from a helper.
Sit to
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/07/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
West Janisch Health Care Center
617 W Janisch St Houston, TX 77018
SUMMARY STATEMENT OF DEFICIENCIES
and right: resident's usual performance is dependent - Helper does all of the effort.
Resident does none of the effort to complete the activity.
Sit to lying: Resident's usual performance is partial/moderate assistance helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort.
Sit to stand: Resident's usual performance is dependent the effort.
Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity.
Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20
Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder.
Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities.
Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet.
Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary.
Transfer: supervision by staff to move between surfaces Resident #25
Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure.
Depression, dependence on dialysis, and dementia.
The resident
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/07/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
West Janisch Health Care Center
617 W Janisch St Houston, TX 77018
SUMMARY STATEMENT OF DEFICIENCIES
During interview on [DATE] at 2:33 p.m., MDS RN said the Social Services Director completed Section E of the MDS and showed the surveyor Section P where use of wander/elopement alarm was captured.
During interview on [DATE] at 2:41 p.m., the DON said she was familiar with Resident #28, and she walks all day.
The DON said the MDS RN was responsible for completing the MDS.
The DON said if the MDS was not accurate it was not a direct accurate reflection of who the resident was.
During interview on [DATE] at 2:47 p.m., the MDS RN said she was going to modify Resident #28's MDS.
During interview on [DATE] at 4:07 p.m., the Social Services Director answered yes when asked if Resident #28 wandered.
The Social Services Director said she completed sections B, C, D, E and Q of the MDS.
The Social Services Director said she documented that wandering behavior was not exhibited as Resident #28 walks the hallways but did not wander outside.
The Social Services Director said Resident #28 had a wanderguard and she was not sure what happened prior for Resident #28 to get the wanderguard.
The Social Services Director said something must have happened for the resident to be at risk for the wanderguard.
The Social Services Director said if the MDS did not reflect the resident accurately then that was false information because you would not be looking for those behaviors.
Record review of the facility's policy MDS 3.0 Completion dated 2023 revealed According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/07/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
West Janisch Health Care Center
617 W Janisch St Houston, TX 77018
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/3/25 at 3:10 p.m., ADON said she completed the baseline care plans for new admissions. ADON said the previous DON preferred to update the care plans and attended the care plan meetings. ADON said the MDS RN was responsible for completing the MDS.
During an interview on 10/3/25 at 5:23 p.m., LVN C, who was the current wound care nurse, said she was only responsible for wound care and not updating the resident's care plans. LVN C said probably DON or ADON was responsible for updating the residents' care plans regarding wound care.
Record review of facility's policy Comprehensive Care Plans dated 2025 revealed The comprehensive care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/07/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
West Janisch Health Care Center
617 W Janisch St Houston, TX 77018
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
maximum assistance for most mobility.
Total dependence for mobility with manual wheelchair for 50- 150 feet.
Record review of Resident #48's undated Care Plan revealed, Focus: a self-care performance deficit r/t requires extensiveto total assistance r/t dementia, late effects of CVA, aphasia, bedbound, incontinence; Interventions: locomotion: utilizes a wheelchair when for proper positioning r/t impaired sitting balance and poor trunk control.
Extensive assistance by one-two staff to turn and reposition in bed and wheelchair.
Lift and extensive assistance by two staff to transfer at all time. Resident #54
Record review of Resident #54's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Quadriplegia (paralysis that affects all limbs), anxiety disorder, weakness, and difficulty swallowing.
The residents advanced directive was full code.
Record review of Resident #54's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, use of a wheelchair, upper and lower body, total dependence for all self-care, mobility, and quadriplegia.
Record review of Resident #54's undated Care Plan revealed, focus: full code; interventions: appropriate care within guidelines of advanced directives; should [resident #54] be found with no pulse, respirations, or blood pressure, start CPR & call 9-1-1 immediately.
Focus: ADL self-care performance deficit and requires cues setup, and/or assistance with ADLs r/t quadriplegia; interventions: usual performance is dependent - helper does all of the effort. [resident #54] does none of the effort to complete the activity or the assistance of 2 or more is required for [resident #54] to complete the activity. lying to sitting on side of bed: [resident #54]'s usual performance is dependent - helper does all of the effort. [resident #54] does none of the effort to complete the activity or the assistance of 2 or more is required for
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/07/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
West Janisch Health Care Center
617 W Janisch St Houston, TX 77018
SUMMARY STATEMENT OF DEFICIENCIES
meal.
There was not a side served with the soup other than cottage cheese with fruit syrup on it. No fruit was served.
The [NAME] reported that she cooks whatever the Dietary Director tells her is the meal.
The menu is not posted in the kitchen.
Review of the Menu board posted outside of the dining room on 10/03/25 at 10:06 AM revealed the following:lunch menu for the day: oven fried chicken, okra/tomato, rice, cornbread, cake with whipped topping.dinner menu: Enchiladas, southwest salad, black beans, apple slices.Review of the Menu board posted outside of the dining room on 10/04/25 at 11:26 AM revealed the following:lunch menu for the day: pork loin, au gratin potatoes, Malibu vegetable blend, rolls, chocolate chip cookies. dinner menu: Unstuffed peppers, green beans, bread, apple slices. In an interview on 10/06/25 at 12:08 PM with the Registered Dietitian for the facility, she revealed the approvals for changes of the weekly menu were made by the Regional Registered Dietitian and she had not approved any menu changes made by the Dietary Director.In an interview on 10/07/25 at 10:16 AM with the Regional Registered Dietitian, she reported the menu process is that the vendor sends out Spring and Summer menus.
The facility started using them for menus in February of this year.
She reported that they try to focus on residents' choices.
They have a food committee of residents that meet and the upcoming menu is reviewed.
The resident council can submit feedback on the meals as well.
Their feedback is used in decision making to change menu items but they stay within the same nutritional value.
The protein will stay the same and swap a vegetable for a vegetable.
They have a substitution log that should be completed and signed off by the Registered Dietitian.
She was not aware if there was a specific food committee at the facility.
She reported they always have an alternate menu available.
Residents should be offered what is on the printed menu or a substitute of equal nutritional value.In an interview on 10/07/25 at 12:26 PM with the Administrator, she reported she was not aware that the Dietary Director was not following the weekly printed menu and substitutions were being made without appropriate approval.
She reported she will ensure the menus and meal preparations are carried out following the policies going forward.
Record review of the facility policy, Menus and Adequate Nutrition, 2025 revision, revealed: Policy section titled Policy Explanation and Compliance Guidelines: 3.
Menus shall be prepared at least two weeks in advance for timely approval and ordering of food.
Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance. 4.
Menus will be followed as posted.
Notification of any deviations from the menu shall be made as soon as practicable.
Substitutions shall comprise of foods with comparable nutritive value.8.
The facility's dietitian or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus.
Facility ID: