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“FACILITY FAILED TO HAVE ENOUGH NURSES TO CARE FOR EVERY RESIDENT IN A WAY THAT MAXIMIZES THE RESIDENT’S WELL BEING”

WINDSOR HOUSTON

LOCATED: 6920 T. C. JESTER BLVD, HOUSTON, TX 77091

BELOIT HEALTH AND REHAB CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO HAVE ENOUGH NURSES TO CARE FOR EVERY RESIDENT IN A WAY THAT MAXIMIZES THE RESIDENT’S WELL BEING

LEVEL OF HARM –ACTUAL HARM

READ TO THE BOTTOM OF SURVEY TO FIND HOW NHAA CAN ASSIST YOU AND YOUR LOVED ONE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews and interviews the facility failed to have sufficient nursing staff trained to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being as determined by resident assessments and individual plans of care for ten of 22 residents (#70, #14, #73, #15, #59, #100, #72, #65, #30, and #97) reviewed for sufficient care being provided by staff.

Facility nursing staff failed to notify the physician when:

Resident #70 did not receive treatments and medications as ordered.

Resident #14 was non-compliant with her diet.

Residents #s 73, 15, 59, 100, 72, and 65 experienced weight loss.

Resident #30’s stat lab and x-ray abnormal results.

Facility nursing staff failed to follow physician’s orders [REDACTED].

Resident #72’s nutritional supplement and blood pressure medications.

Resident #62’s tube feedings.

Resident #65’s health shakes with meals.

Resident #97’s hand rolls and treatments to the insides of her hands.

Resident #15’s heels were not floated while in bed.

Resident #15’s tube feeding.

Facility nursing staff failed to effectively:

Assess and manage the pain of Resident #70.

Review Resident #30’s allergy history prior to administering new medications.

These failures affected ten residents and placed 98 residents at risk of not receiving the medical care and treatments required for them to maintain their highest level of health and function.

Resident #70’s pain was not assessed and managed on a daily basses. Assessments would reflect her pain intensity at a 10 on a scale of 1-10 with 10 being the most severe with no documentation of pain medication or alternate pain management being provided to the resident (See F309 and F425 for evidence).

Resident #14 had a medical condition which resulted in her aspirating thin fluids into her lungs. The physician ordered nectar thickened liquids for the resident. The resident refused the nectar thick liquids and drank thin liquids from November 2014 to March 2015 without the physician being consulted. (See F157, F323, and F365 for evidence).

Resident #73 had a weight loss of forty pounds in five months and the dietitian’s recommendations to change the resident’s tube feeding to increase nutritional intake was not communicated to the physician or implemented. (See F157 and F325 for evidence).

Resident #15 experienced a weight loss of 20 pounds in three months and the dietitian recommended an increase in her tube feeding on 2/12/2015. This was not communicated to the physician until 3/12/2015. The physician ordered the increase on 3/12/2015 which was not implemented by the facility staff until 3/25/2015. (See F157 and F325 for evidence).

Resident #59 experienced a weight loss of nine pounds in one month and the dietitian recommended med pass supplement which was not communicated to the physician or implemented. (See F157 and F325 for evidence)

Resident #100 experienced a weight loss of nine pounds in one month and the dietitian recommended med pass supplement which was not communicated to the physician or implemented. (See F157 and F325 for evidence).

Resident #72’s physician changed his blood pressure medications which were transcribed wrong onto the MAR and were administered by staff not as ordered by the physician. (See tag F282 for evidence).

Resident #65 experienced a weight loss of 14 pounds and the dietitian recommended health shakes be added to meals which was not communicated to the physician or implemented. (See F157 and F325 for evidence).

Resident #30 had stat lab and x-rays conducted at the facility on 3/20/2015 and the physician was not notified of the results until 3/23/2015.

Resident #30’s medical history revealed she was allergic to the antibiotic [MEDICATION NAME]. When the physician ordered this medication staff administered two doses to the resident from the emergency kit prior to being notified by the pharmacy of the allergy. (See F157, and F309 for evidence).

Resident #97 had severe contractures to both hands with fists tightly clinched. The resident had excoriated and odorful dead skin inside her hand. She was not provided hand rolls or treatment as ordered by the physician. (See F282 for evidence).

Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.

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