The Carlyle At Stonebridge Park
The Carlyle at Stonebridge Park in Southlake, TX — inspection on August 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
Summary to identify any and all residents who were may have been admitted with or given orders to insert a urethral catheter to ensure appropriate placement and flow.
This will occur daily for 2 weeks, weekly for 2 weeks and then monthly. On the weekends and holidays, the Nurse Supervisor/Designee will complete the audit/review.
The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review.
The DON/Designee will monitor this process. **Any staff who are not present to complete the in-service by 8/21/2025 will be required to complete the in-service at the start of their next shift before beginning work.
New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift.
The education will be conducted and monitored by the DON/Designee.
Quality Assurance: Results of all monitoring by DON and Unit Manager shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon.
The DON will be responsible for bringing the results of the monitoring to the QA committee.
Completion Date: 08/21/2025 Monitoring the facility's Plan of Removal included the following: Observation on 08/20/25 at 9:45 AM revealed Resident #1 was no longer at the facility.
Record review of the In-service Training Report dated 08/21/25 reflected 12 charge nurses were educated on Foley insertion, verify placement, documentation, physician orders, change of condition, complete transfer form.
Further review of the training revealed each charge nurse was given a competency test and a skills assessment checked off by nursing management.
Interviews on 08/22/25 from 11:26 AM to 3:29 PM from nurses from various shifts were the DON, ADON, Treatment Nurse, RN A, LVN B, LVN D, LVN F, LVN G, LVN H, LVN I, LVN J, RN K, RN L, and LVN M.
All staff were able to identify the following: - What type of documentation is required with resident that have Foleys; (i.e. color, odor, urine output, urine retention, discomfort to area and size of catheter and balloon inflation)- How to insert a catheter using sterile technique in males and females. (insert until there is urine return and go farther if resistance is felt) - What to do if they feel resistance when inflating the catheter balloon. - How to remove a catheter (pull the same amount of fluid that was inserted in the balloon, and gently pull out)- What to do if the is blood noted upon removal (do not remove and call the physician for orders)Each charge nurse had a competency test and skill assessment as part of their in-service.
Review of the audits dated 08/21/25 revealed there were 5 residents with catheters and there were no issues identified with the resident's catheters.
Observation on 08/22/25 of catheter care for Residents #2, #3, and #4 from 10:15 AM to 11:06 AM revealed appropriate technique was used, clear urine was flowing in the output bags, and there were no issued noted.
There were no residents that required catheter insertion or changing.
The Regional Nurse Consultant and DON were notified on 08/22/25 at 3:45 PM, the Immediate Jeopardy was removed.
While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.
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