Deficiency Records for Spring Branch Transitional Care Center
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-27 | 2022-03-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-03-10 | 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 | 2022-01-27 | 2022-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-03-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-01-27 | 2022-03-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-27 | 2022-03-10 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2022-01-25 | 2022-03-08 | N |
| 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 |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-01-25 | 2022-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-25 | 2022-02-28 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-01-25 | 2022-02-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-25 | 2022-02-28 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2022-01-25 | 2022-02-28 | N |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2021-07-04 | 2021-07-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-09 | 2020-11-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-10-09 | 2020-11-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-09 | 2020-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-09 | 2020-11-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-09 | 2020-11-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-10-09 | 2020-11-13 | 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 | 2020-10-09 | 2020-11-13 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-10-09 | 2020-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-09 | 2020-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-09 | 2020-11-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-10-09 | 2020-11-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-09 | 2020-11-06 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-10-09 | 2020-11-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-09 | 2020-11-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-09 | 2020-11-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-10-09 | 2020-11-06 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-10-09 | 2020-11-06 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-07-04 | Not Fixed | Y |
