Date Printed: 06/06/2014 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FDR MEDICARE II. MEDICAID SERVICES OMB No. gaze-mm 
STATEMENT OF DEFICIENCIES (XI) MULTIPLE CONSTRUCTION 9(3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING

675793 05123I2014
NAME OF PROVIDER DR SUPPLIER STREET ADDRESS CITY, STATE ZIP CODE
1737 LOOP 
LEXINGTON PLACE NURSING 8: REHABILITATION
HOUSTON, Tx mos
I9 2? SUMMARY STATEMENT OF DEFICIENCIES . ID PROVIDER-S PLAN OF CORRECTION 5 our
page?; (EACH DEFICIENCY MUST BE PRECEDED av FULL REGULATORY I IEACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG 0R LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE I DATE
I DEFICIENCY000.? INITIAL COMMENTS one fit-"13324 turn-9 wry. I
. aim Stride I
9f WSW incident and Complaint I I andj L'rtithtid and the I
I Investigation .
I .. I?m 3' 

Entrance Date; #2314 I In I

213.2% - 9i. Emmott I
.15 to 

.,

tofuienrles organ 

I Facility Census: 142 - I

I Intake 671750. 672418. 673393. 671941. I 

I675164.675093. 674778, 672074.67?2416 and I I I I

Images, I I

I I PERM i Karrewur. I.
I ?519 .131 ails? Ev wait}: omitting:

 

I Abbreviations used: I


I CNA Certified Nursing Assistant I
I CR Closed Record I

i?f?il?hig 

i DON Director of Nurses I I
I FR French (refers to size of catheter) - I i

gm gram
I
IDT Interdisciplinary Team

LVN Licensed Vocational Nurse
MA Medication aide I I
I

I MAR Medication Administration Record

micrograms



MD Med'cal Doctor
I MDS inimum Data Set DIRECTOI WREPRESENTATME-s SIGNATURE can DATE

?77

a an asterisk denotes a de?ciency which the institi?ion may be amused from com Midinu It is determined that other

 

 

 

 

 

 

 

 

 

 
   
  
  
  

1y de?ciency stat
"Iards prom au 1 mtedion to the patients. [See instructions.) Exceot tor nursing homes. the ?ndings stated above are discloeebio 90 days totlowing the date of
whether or not a of correction to prodded. For nursing homes. the above ?ndings and plans of motion are disclooabie t4 days following the date mesa

moments are made table to the facility. If de?ciencies are cited. an approved plan of correction to requisite to continued program participation



 

Mel-mart" 'irm ?m ??69

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID 

Date Printed: 06106/2014 3 
FORM APPROVED

me 59 gags-mar

 

STATEMENT OF DEFICIENCIES PROVIDERJSUPPLIERJCLIA
AND PLAN OF CORRECTION IDENTIFICATION 

 

 

B75793

(X2) MULTIPLE CONSTRUCTION
A BUILDING

WING

(X3) DATE SURVEY
COMPLETED


05/232014

 

 

 

 

NAME OF PROVIDER DR SUPPLIER

LEXINGTON PLACE NURSING GI REHABILITATION

STREET ADDRESS. CITY. STATE. ZIP CODE
1737 LOOP 
HOUSTON. TX 77008

 

 

SUMMARY STATEMENT OF DEFICIENCIES 
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY I
0R LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

ID
PREFIX I

I his;
i 
DATE

OF coeaecrioe
(EACH CORRECTIVE ACTION SHOULD es
CROSS-REFERENCED TO THE APPROPRIATE

- DEFICIENCY)

I
TAG

 


000 Continued From page 1

I

I mt milliliter .

I NP Nurse Practitioner .
0A Quality Assurance I

RN Registered Nurse .
SW Social Worker I

. times

202 I DOCUMENTATION FOR
ss:E i TRANSFERIDISCHARGE 0F RES

When the facility transfers or discharges a resident
I under any of the circumstances speci?ed? In
. paragraph through of this section. the
I resident's clinical record must be documented. The
documentation must be made by the resident?s
physician when transfer or discharge Is necessary
I under paragraph or paragraph of
.this section; and a physician when transfer or
discharge Is necessary under paragraph of I
this section.

I
i i
I I
This REQUIREMENT is not met as evidenced by: I




I

I Based on interview and record review. the facility

I failed to have a physician discharge summary for 3 I
of( Residents CR 4:15.13 and #14) of eight reSIdents I
reviewed for discharge. 

I This failure affected 3 discharged residents and I

I placed 142 other residents at risk of not having I

I physician discharge summaries to indicate types of I

i services received prior to admission and post .
discharge from the facility.

I
I
I 

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ID: 4810 Page 2 07159

LPN 

 

Date Printed: 06/06i2014 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
RVICES . 91
STATEMENT OF DEFICIENCIES (X1) PROVIDEWSUPPLIEFUCLIA (X2) MULTIPLE CONSTRUCTION 0(3) DATE SURVEY
AND PLAN OF CORRECTION NUMBER: A BUILDING COMPLETED
0
675793 a 0512312014

 

 

 

 

NAME OF PROVIDER 0R SUPPLIER

LEXINGTON PLACE NURSING a. REHABILITATION

 

STREET ADDRESS, CITY. STATE, ZIP cooe
173? LOOP 
HOUSTON, TX 77008

 

PROVIDERS PLAN OF CORRECTION

 

 

 

3(4) ID SUMMARY STATEMENT OF DEFICIENCIES fl.) 
PREFIX I (EACH DEFICIENCY MUST as PRECEDED sv FULL REGULATORY PREFIX IEACI-I CORRECTIVE SHOULD BE comam
TAG 0R LSC IDENTIFYING INF ORMATIONI . TAG . TO THE APPROPRIATE BATE
. DEFICIENCYContlnued From page 2 I 20211.. .. . I II
I Findings Includeif?l'I I I I I
CR #15Record review of CR #15 5 closed record revealed
a 70 year old male who was admitted to the facility

. on 08/05l12 and was discharged home on

. 10I1BI12. CR #15 was admitted with multiple

,1 medical conditions that including Hypertension, End

I Stage Renal Disease and Dyslipldemia.

I

I Record review of CR #15'5 clinical record revealed

I a physician's discharge summary that was blank

I and not signed by the physician.

I In an interview on 05!23!14 at 2:30 pm the DOM
I reviewed the clinical records and he said that CR
#15?s physician had not completed the discharge
I summery. He stated he was not the DON when this
resident was in the facility 

I cs #13:

I Review of CR #13's Admission Record, revealed

I the resident was 100 year old female admitted to

I the facility on 11:15i13 with diagnoses of Pressure

I Ulcer. Lack of Coordination, Muscle

I Weakness-General. Orophary'gealI

Multiple Sclerosis, Quadriplegie. Depressive
disorder. Diabetes Milletus and Spasm of Muscle.

The resident was discharged on 01/13!14.

- 

I Record review of CR 1113's nursing notes dated

revealed she was transferred to the

hospital for wound care treatment.

I

CR #13'5 Discharge Summary, dated 01/13/14.

reflected an additional diagnosis of wound care

I



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I


I

Facility ID: 4510 Page 3 of 169

LPNR000003

 

 

Date Printed 06/06/2014 

 

 

 

 

 

 

 

 

 

I Review of Resident #13's entire closed clinical 
record revealed prior to the resident's discharge the 
facility did not notify the resident or the legal .

representative of the discharge, the reason for the

discharge andior that the resident would not be

i allowed to return to the facility afterthe hospital

I stay. There was no documentation by the physician

to justify why the facility could not meet the

I resident's needs.


I Resident #14 I
1

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE 8: MEDICAID SERVICES NQ. 
STATEMENT OF DEFICIENCIES (x1: 0(2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A BUILDING

675793 5 WING- 052312014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE
LEXINGTON PLACE NURSING 8. REHABILITATION LOOP 
HOUSTON. TX 77008
i3?) ID SUMMARY STATEMENT OF DEFICIENCIES ID I PROVIDERS PLAN OF CORRECTION 4x5;
ngpIx . (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX i (EACH CORRECTIVE ACTION SHOULD as I COMPLETION
MG 1 0R IDENTIFYING TAG TO THE APPROPRIATE DATE
i I . DEFICIENCYContinued From page 3 202 .t v.21 ?931% h; 
I treatmentReview of Resident #14'5 Admission Record, I

revealed the resident was a 85-year old female I
admitted to the facility on 11:23? with diagnoses I
that included Pleural Effusion, Anxiety Disorden 
Lethargy. Generalized Pain. Senile Dementia,

I Glaucoma. Osteoporosis. Lack Of CoordinatiOn 

. and SupraCondyl Fracture Closed.

I Nurse?s Notes. dated 08I29i13. revealed IResident
#14 revealed resident was transferred to hospital
. due to lethargic and decreased oxygen saturation. I





I Review of Resident #14'5 entire closed clinical

I record revealed prior to the resident's discharge. the
facility did not notify the'reeident or the legal I
I representative of the discharge as soon as I
I

practicable, There was no documentation by the
physician to reflect the health and safety of
individuals In the facility was endangered.

I


I
I


RM CMS-ZSGTIDZ-GB) Preview Versions, Obsolete Event 

Bates Labeled by Merman Law Firm

Facittly ID: 4510

 

 

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Haida 4T1 vita-J: 

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armada i: tire. I. (EtitlQili a: valved. Mitt.

 

all; assets trimmer;

$965451!in

 

 

 



 



Page 4 oi 169

 

 

 

Date Printed: 06/06f2014 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE I MEDICINE) SERVICES OMB No. 0935-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED
A BUILDING

?75793 05:23:2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESSI CITY. STATE, ZIP CODE
1731 LOOP 
LEXINGTON PLACE NURSING 8 REHABILITATION HOUSTON, TX 77008
W) In summer STATEMENT OF DEFICIENCIES ID I PLAN OF CORRECTION Ist
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY I PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG OR LSC IDENTIFYING INFORMATION) TAG I CROSS-REFERENCED TO THE APPROPRIATE DATE
I I DEFICIENCYContinued From page 4 202! .

Interview with the ADON on 05/15f14 at 11:30 a mu 
she said that when a resident was discharged the I
discharge summary should include where they were .
going. their medication and treatment if the resident I I
was transferred to a hospital, she said she was not I I
sure how many days either 120 days. 60 days or 30 
days for the medical discharge summary to be I 
completed. No explanation was provided about i
why these documentation was not included in the 
resident's medical records I I 
i I
I .
The CMS form 672 llsted the census of 142 I I
residents224i 483.13(c) PROHIBIT I 224i ?2.22 
i I

I . :?itz?it he Ineliigetakee- I

I The facility must develop and Implement written policies and procedures that prohibit mistreatment. I I ?Ql?m?eEmily" 992% 
neglect. and abuse of residents and I I been Inferno hy the deligieiif I
misappropriation of reSIdent property0.21.499 L?i him I I died I

I

I I .?e.t..w.ere.tewd i
.3 I . I. I
This REQUIREMENT is not met as evidenced by: I I I

I I been Iii?etleiged I
Based on observation. Interview and record review I I iremtiie 
the facility failed to develop and implement policies I I to be promded gimp; Adams. 
and procedures that prohibit neglect for 4 of 13 I 5:31 

i residents#75) I e: Jena. I

I reviewed for neglect as evidenced by: . I

I

I -Failure to protect Previous Version-I Obsolete Event Facility ID: 4810 Page 5 Of169

Bates Labeled by Merman Law Firm 

 

Date Printed: 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EQB a MEDICALQSERVIQES -
STATEMENT OF DEFICIENCIES (XI) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED
A BUILDING

675793 a was 05/232014
NAME or PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 
173? LOOP 
LEXINGTO LACE NURS 8. REHABILI ATION HOUSTON. TX "003
my ID I SUMMARY STATEMENT OF DEFICIENCIES to I PROVIDER-s PLAN OF CORRECTION (st
PREFIX 1 (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE I 
TAG OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
i DEFICIENCY224. Continued From page 5 i 224' .. ., I
I 04i22/2014 CR #1 and CR #2 were found in their 'room unresponsive with severe head Injuries CR Iii-i9 ?i 
was pronounced dead in the facility CR #2 was If. him it 
'transported to the hospital where he passed away 
I on 04,2314 'roommates for CR #2 and CR #1 was arrested as a I 
homicide' suspect I I milea- _t'I --.- . I I
I
-Failure to develop policies to support coordination 
. of care and effective communication with contracted I 
I services to. include'the and m? I tine-fax edit? . will iv;- gjtit pies: 
I sewice groups to vIolent . I - I
behaviors and put appropriate interventions In place I WWII Dad's??! kiwi-:5 Wit? It? 
to prevent residents? injuries or death. I when.? I: {[11 weFailure to provide Specialized training to the staff . I Innate-.2; It Ii. it?t 
to recognize, understand. and intervene with I
residents that have diagnoses and 35321.1 Wit. .1: as. it? Vi:- $131131: I
I conditions. I I slot-IL I: _ano pr; Itiice' an; elation which I
Qti. I
I - Failure to have a policy In place to screen tufavecmemaeInsetsite- . I
admissions to determine if they were appropriate for I I {if I
I the facility. CR #75 was admitted from a I I tsetse? I
I correctional facility on 02120114. CR #75 exhibited I Jerome I
sexually inappropriate behaviors in the facility. was I .It't?ll?it??. .
sent to the hospital on 05111114. CR #75 was I ed" tie.LI t0. Idealist mantles. In. I
readmitted on 05113I14 and placed In the secure ?Jr. flit-LAKE: Qt aat?dji?y. 
unit with residents with dementia. Sexually I the. lt?ttrlitIOES . I
inappropriate behaviors. to include masturbation. 3' EL include Lht; 
I escalated on 05I1 3/14 and CR IRS was sent back I midget-?it. 
to the hospital. I euttIiesatigg-I'Ire. I
I . Elf-.715 mitts-Irate: it neg-a I
An was identi?ed on 1315;16:14 at 3:08 pm. White I speci?eesvctilaith .
the IJ was removed on 052314 at 12: 40 pm the I !26:3 3.4- we lei? Miter: eat.
facility remained out of compliance at a scope I .I?Id?idthi :3 eate 33' leliilidesqs-Ls'ie? I
pattern and a severity level of actual harm due to I I arable-I Each. I. {16.5.1 11 Insider was I
facility needing more time to monitor the plan of I
removal for effectiveness. I I 'WWILELL-?d?l??t?iiglb?i.
. sewerPrevious Version: Obsolotl Event IDIU4F81I Facility "14610 Page 5 M169

Bates Labeled by Merman Law Firm

LPNR000006

 

Date Pnnted? 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAID SERVICES 3 -
STATEMENT or DEFICIENCIES (X1) (sz MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING

?5793 ?3 0522322014
NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE
LEXINGTON PLACE NURSING 8. REHABILITATION 1737 LOOP 
HOUSTON. TX 77008
In, .D I STATEMENT OF DEFICIENCIES IO PROVIDER-s PLAN OF CORRECTION as;
new 3 (EACH DEFICIENCY MUST as PRECEOEO av FULL REGUIATORY PREFIX CORRECTIVE ACTION SHOULD as COMPLETION
TAG OR IDENTIFYING I TAG I TO THE APPROPRIATE I UME
I DEFICIENCY224I Continued From page 6 224' . I. I -- - 
idi?i?i??flThese faIIures resulted In the death of two I if: .quf. '22: . I, I
residents? affected 2 other resident and placed all 
- I .EHI. ?Iii InI-Itrneiaige 2?;i 1

142 residents at risk of living in an unsafe
I environment. fear, injuries and being assaulted by
other residents

Intake 571?50. 675184, 67?5098




I Findings include:

I Record review of the incident reported by the facility
I to DADS and dated 0412314 revealed that on
04i22l14 at around 11 00 pm; CR #3 was found

I attempting to leave the building. CNA A redirected

I the resident back to his room and upon entering
theyr found CR #1 and CR #2 unresponsive and
Ibleeding from their heads. Nurses were Informed.

I EMS was in the building for an unrelated incident
and assisted with the emergency. CR #1 was

I pronounced dead in the facility and CR #2 was
transported to the hospital where he passed away

I on D4l23i14. The police was notified after the

I incident and arrested CR #3 (who was one of the
roommates homicide

I suspect.

 

ICFI 

Record review of CR #1's tile revealed that he was
a T5 year old male admitted to the facility on
05f11f2012 with diagnoSes that included
'Congestive Heart Faildre. Peripheral Vascular

I Disease Diabetes. Hypertension and muscle
atrophy. His primaryIlanguage was Spanish

Record review of CR #1 quarterly MDS
I assessment dated 04l01I14 revealed that he had


Previous Versions Oblolato



.

..

Bates Labeled by Merman Law Firm

:rap t. Her. 5: 
I ?523: IQ in?? 2 i? It i?gi 5? I
I 53.3.5112 II upon I'Ijig; instep the: 
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dissessiesaw Dated I

daisies aseceiatiunsg xiv-c .
?lijii?iwquIF-Ji with in; Soc: tel Workers prior Waiters-Mi eta Irena 22,132.. wits 
I intec- Disc??lin my team any airborne? -

fr Ihg Ali otafi sell: I
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wager, and. (if Nausea -
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Elsi a. this: station. skies. I
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mantras 
needed for. hails-L 
I Cheeses additional. I
referrei i terrorist to; emits
Deeds? -

LII).

 

 

 

Foctlity ?14610 Page 7 of 169

LPN R000007

 

Date Printed 06106e'2014 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
Ft MEDIQARE It: MEDICAID SERVEES 0 MD. 09350391
STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA MULTIPLE CONSTRUCTION (X31 DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A BUILDING

575793 051232014
NAME cs PROVIDER 0e SUPPLIER eraser CITY. STATE, ZIP cone
LEXINGTON PLACE NURSING 8- REHABILITATION 1737 LOOP 
I HOUSTON. TX T7008
(x4) IQ SUMMARY STATEMENT OF DEFICIENCIES I iD I PROVIDERS PLAN OF CORRECTION I 
p?EI-?jx I (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY I PREFIK I (EACH CORRECTIVE ACTION SHOULD BE I COHPLETIOH
TAG I CIR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE I DATE
224 Continued From page I 22.4  I I
I no cognitive de?cits and required extensive assistance of one person for bed mobility, and two I . 
IpeopIe for transfers and personal hygieneInf, II I I It I
Record revtew of CR #15 serwce I I . II. II. Iii: 
I progress note dated 04116114 revealed that received therapy for depression. helplessness and . II I
I withdrawal. No behavior issues were marked Iform90:5; I
I CR #2 njgnitqrt: ?as sure the diff: rieIIt I

. Record review of CR #23 admission sheet revealed I I Bali 51:; 196334 v1.1: II rv?iiI II
he was 50 years old and was admitted on 10/21l11. I I [51.51553sz 
His diagnoses included Paralysis Agitans, Epilepsy, I I 
History of a Transient Ischemic Stroke, Dementia i I 1LT Rain .
with Behavioral Disturbances, Personal History Poliomyelitis, Abnormality of Gait, Lack of I. I a swarms hires tor a: :Ir starter: wit I
I CoordinatronuMuscle Disuse Atrophy. and I more?; Ian tie: first 1? week-i; I
I Depressrve Disorder. I I
I inQIfI m3?. .i?i 
I . . wilt he tr; I
I Record review of the Clinical . I fit I If: I
I Treatment Plan for period from 0322013 reasons: I . II 
I revealed a Brief rating scale with ratings I I {1341165 .35 II
I that ranged from none to very severe. OR #2 had i I?rain?ih will its "intuitthe following marked: I I thy/192831
I II ?at? CT vafld . .J .-.. . ..
LIE, I I
Severe: somatic concerns I
Moderate severe: depressions; I 
I Moderate: tension and anxiety Further review of the term revealed a narrative note I I i
I indicating that CR #2 struggled with depression and I I
family Issues No behaviors issues were marked on I I I
I the form Previous Version: Obsolete Event Facility ID 4610 Page a of 169

Bates Labeled by Merman Law Firm 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE i MEDICAID SERVICES

Date Printed. 06106.12014 
FORM APPROVED

OMB NO. 093343.391

 

STATEMENT OF DEFICIENCIES (XII PROVIDENSUPPLIEFUCLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

675 793

 

 

(X2) MULTIPLE CONSTRUCTION
A BUILDING

WING

IxaI DATE SURVEY
COMPLETED




 

 

 

NAME OF PROVIDER OR SUPPLIER

LEXINGTON PLACE NURSING 5: REHABILITATION

 

1737 LOOP 

STREET ADDRESS, CITY. STATE. ZIP CODE

HOUSTON. TX 77003

 

(x4; .0 SUMMARY STATEMENT or DEFICIENCIES
PREFIX . (EACH DEFICIENCY MUST as PRECEDED av FULL REGULATORY
mg I on IDENTIFYING INFORMATION)

ID PROVIDERS PLAN OF CORRECTION {15}
PREFIX (EACH CORRECTIVE ACTION SHOULD BE . COMPLETION
TAG CROSS-REFERENCEO TO THE APPROPRIATE DATE

I

 

224I Continued From page 8

i CR 
I

Record review of CR #3's admission sheet revealed
he was 56 old and was admitted on 9/29l11. His

I diagnoses included Asthma. Muscle Weakness.
Abnormality of Gait. Lack of Coordination Muscle
Disuse Atrophy. Cardiac Atrial
Fibrillation Diabetes Mellitus ll, anxiety disorder

I recurrent and convulsions

. He was discharged from the facility on D4123t14

I Record review of CR #3 quarterly MOS

. assessment dated 04I15114 revealed that he was

. alert, oriented and able to make decisions. Further

. review revealed that the mood section was marked

I with a yes for feeling down or depressed.

i Behavior section was marked with 0 meaning

I behavior not exhibited Functional status section
was marked as limited assistance of one person for

I locomotion and the use of a wheelchair.

I Record review of CR care plan with onset date

I of 08/22/13 and last update of 01f29i14 revealed
problems related to alteration in 

well-being as exhibit by recurrent mood and

behavior changes. Resident was easily agitated.
irritable and nervous related to 

I rdepression and anxiety disorders Further review of
the care plans revealed that the resident was able

I to ambulate but had an unsteady gait and also used

I a wheelchair.

I During an interview on 4.12314 at 11:15 p. m. CNA A:
I said that on 4.22114 at approximately 11 .-20 11 25
i she overheard someone telling a

I

RM Previous Versions Obsolete Event 

10:4610

Bates Labeled by Merman Law Firm

4
Page 9 of169

LPNR000009

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Date Printed: 06f06/2014 

FORM APPROVED
OMB NO. 0933-0391

 

QENTERQ FQR MEDIQAEE ILMEDICAID SERVICES

STATEMENT OF DEFICIENCIES (Xi) 
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

675193

 

 

(X2) MULTIPLE CONSTRUCTION
A BUILDING

WING

 

(X3) DATE SURVEY
COMPLETED


0512312014

 

 

NAME OF PROVIDER 0R SUPPLIER

LEXINGTON PLACE NURSING REHABILITATION

173? LOOP 

 

STREET ADDRESS, CITY. ZIP ODE

HOUSTON, TX T7008

 

(X41 .9 SUMMARY STATEMENT OF DEFICIENCIES 
prism . (EACH DEFICIENCY near as PRECEDED av FULL REGULATORY I
ma OR LSC INFORMATION)

I PROVIDERS PLAN OF CORRECTION (as,
PREFIX I CORRECTIVE ACTION SHOULD eE COMPLETION
TAG TO THE APPROPRIATE om:

DEFICIENCY)

 

224 I Continued From page 9

i nurse to open the back door. CNA A saw CR #3

wheeling his wheelchair and trying to leave as he

said he wanted to go to the hospital cafeteria

i because he was hungry, but he turned around She 
began walking up the hallway on Station 4 headed

towards the lobby to reach CR #3 room in the

i 100 wing. CNA A said she noticed some Spots on I
the ?oor that were red but also had clear ?uid so

I she could not identify it. She said she noticed the
concentration of the spots getting closer as she I

I approached CR #33 room. She said the door was
cracked open so she knocked. announced

I herself, and entered. CNA A said she saw CR #1'5 1

I pillow saturated with blood and the resident was 

I slumped over the bed. She said she called the 
nurse for assistance.

1 
Further Interview at the time DNA A said that CR #3 i
did not have behavior issues she knew of but that 
he would point to OR #1 and circle his head in the .
he's crazy" sign. I

 

in an interview on at 12:55 am. LVN I

con?rmed that CNA A followed CR #3 back to his I

I room because he said he was hungry and she

. wanted to get him something to eat. Two to three

I minutes after CNA A left. she was calling the code I

I blue. LVN said when he got to the resident 

I room he saw the mess and i was in shock. I Ire 

I never seen something like that. He said CR I

. brain was on the ?oori LVN said was

I on his back. it tool-ted like a machete or an axe cut I
his head apart. He said there was blood and

I brain matter on the ?oor. LVN said he called 911

I but they said they had already received a call. He

I noted that the paramedics

 




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FRM Previous Versions Obsolete Event 


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Bates Labeled by Merman Law Firm

Page 10 of169



 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE

MEDICAID SERVICES

Date Printed: 06i06l2014 3:16 42PM

 

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

 

(X1) PROVIDERISUPPLIERICLIA
IDENTIFICATION NUMBER

675793

 

 

 

NAME OF PROVIDER 0R SUPPLIER

LEXINGTON PLACE NURSING REHABILITATION

 

 

(my ID I SUMMARY STATEMENT OF DEFICIENCIES
pREle (EACH DEFICIENCY MUST BE PRECEDED av FULL REGULATORY
TAG I OH IDENTIFYING INFORMATION)

 

I
224 Continued From page 10

were already in the building and as CR #2 was
I still breathing, they ran him next door (the hospital).

LVN said the hospital called the facility and told I

I them they believed it was a gunshot wound LVN 
said the police found a wheelchair arm in the trash

I in the lobby. LVN said CR #3 acted like nothing

I had happened but the sink in his room was full of

I blood. LVN said CR #3 was arrested that night.

I In an interview on 4/23/14 at 1:30 am. CNA said
she was familiar with CR #1 and #2 She said
none of them had ever showed any types of

I behaviors.

I In an interview on 404/14 at 2:56 pm. SW A said
that CR CR, #1 and CR #2 all occupied a 4

I bedroom ward. She said that CR #3 was moved to

I that room a while ago because he was no longer

Medicare-eligible and the facility wanted to ?nd

I roommates for him who spoke Spanish too.

In an Interview on at 12:45 pm. with a
I police investigator he said that according to the

 

information he obtained during interviews. the
nursing staff said that CR #3 had a long history of
telling people about the two roommates he did not

I like, saying the}I were cry babies and whiners 
[referring to CR #1 and CR He said that the

worked.

I


facility had security cameras but none of them

I In a phone interview on 04I25I14 at 2:40 pm a

I family member for CR #1 said that CR #3 was
rude. would pick on CR would talk to

himself, and believed the staff were trying to poison

I him. In further phone interview with

 

IRM Previous Versions Obsolete Event ID: U4F611

Bates Labeled by Merman Law Firm

FORM APPROVED
8-0 91 .
Ixzi MULTIPLE CONSTRUCTION IxaI DATE SURVEY
A BUILDING COMPLETED

5 WING 
STREET ADDRESS. CITY. STATE. ZIP cone
1737 LOOP 
HOUSTON. TX 77008
ID PROVIDERS PLAN OF CORRECTION i 
parrot (EACH CORRECTIVE ACTION snooto BE common
TAG I CROSS-REFERENCED TO THE APPROPRIATE 5 one
. DEFICIENCYFacility "14510 Page 11 ?159


 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID SERVICES

Date Printed: 06l06it2014 

FORM APPROVED
0MB NO. 0938:0391

 

GATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERJCLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

 

675793

 

(K2) MULTIPLE CONSTRUCTION
A BUILDING

WING .

 

DATE SURVEY
COMPLETED


Damp?

 

 

I NAME OF PROVIDER OR SUPPLIER

LEXINGTON PLACE NURSING REHABILITATION

 

STREET ADDRESS. CITY. STATE. ZIP CODE

1737 LOOP 

HOUSTON, TX T7008

 

(X4IID SUMMARY STATEMENT OF DEFICIENCIES
sham I (EACH DEFICIENCY as PRECEDED av FULL REGULATORY
TAG 0R IDENTIFYING INFORMATION)

IO
PREFIX
TAG

PLAN or CORRECTION 'ng
(EACH CORRECTIVE ACTION SHOULD as COMPLET on
I CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

 

224 I Continued From page 11

another family member she said that CR #3 was a

bully. He did not go to the cafeteria because he

thought the staff was trying to poison him. He I
thought the cameras were there to monitor him. He

. stayed in his room because he thought staff was

watching him. He would stand in the doorway of his 
room and curse at people passing by He threatened

I to get his guns and knives and kill everyone." She I
said that they had complained to the facility and had
talk to the receptionist to ask her to move CR #1 to I

I another room. but this was not done. -

 

 

I In an interview on 04128i14 at 4 20 pm the

I Receptionist denied receiving a room change

I request from CR 5 family member She also said I
that the family did not report any concerns or

complaints to her about CR I

I in an interview on 4/24/14 at 6:19 pm. with LVN 0
revealed she had been working in the facility 3 I
months. She said every now and then someone 

I would be up at night in that room {referring to the I

I room for CR #2 and butthat it was one of 
my quietest rooms. She said all the gentlemen in

Ithet room "were nothing but polite and that she
had never seen them argue f; 

I In an interview on 04t29l14 at 2:00 pm LVN said
that she was the charge nurse for the 2-10 shift.
She said that she had worked with the residents 
involved in the incident and she had no knowledge
I of any issues between them. She said that CR #3
had no behaviors problems and she was not aware I
I of any requests for room change from interview on 04:29? 4 at 2: 45 pm CNA said I
that he did the last round to check on CR #1



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224

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Facility "sz10

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