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Deficiency Records for Spring Branch Transitional Care Center
A list of the most recent deficiencies for Spring Branch Transitional Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Spring Branch Transitional Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. | Health | 2024-05-22 | 2024-05-31 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-16 | 2024-04-28 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-04-19 | 2024-04-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-04-19 | 2024-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-19 | 2024-04-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-19 | 2024-04-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-19 | 2024-04-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-19 | 2024-04-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-04-19 | 2024-04-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-04-19 | 2024-04-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-19 | 2024-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-19 | 2024-04-25 | N |
| Dispose of garbage and refuse properly. | Health | 2024-04-19 | 2024-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-19 | 2024-04-25 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-04-16 | 2024-04-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-16 | 2024-04-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-16 | 2024-04-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-16 | 2024-04-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-11-10 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-10 | 2023-11-17 | N |
| Dispose of garbage and refuse properly. | Health | 2023-11-10 | 2023-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-10 | 2023-11-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-10 | 2023-11-17 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-10 | 2023-11-17 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-11-10 | 2023-11-17 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-11-10 | 2023-11-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-10 | 2023-11-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | 2023-11-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-24 | 2023-11-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-24 | 2023-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-24 | 2023-11-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-18 | 2023-08-03 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-27 | 2023-04-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-27 | 2023-04-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-27 | 2023-04-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-27 | 2023-04-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-27 | 2023-04-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-27 | 2023-04-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-27 | 2023-04-19 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-03-21 | 2023-04-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-26 | 2023-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-01-30 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-12-16 | 2022-12-19 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2022-12-16 | 2022-12-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-16 | 2022-12-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-16 | 2022-12-19 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-16 | 2022-11-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-31 | 2022-11-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-20 | 2022-09-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-20 | 2022-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-20 | 2022-09-24 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-20 | 2022-09-24 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-20 | 2022-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-25 | 2022-04-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-25 | 2022-04-27 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-25 | 2022-04-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-28 | 2022-03-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-28 | 2022-03-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-28 | 2022-03-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-28 | 2022-03-04 | Y |
| Post nurse staffing information every day. | Health | 2022-02-28 | 2022-03-04 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-28 | 2022-03-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-16 | 2022-01-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-28 | 2021-11-28 | Y |
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