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Based on interview and record review, the facility failed to ensure the medical record of Patient ID # 1 contained complete documentation related to evaluations, results, and interventions.

The facility failed to ensure the medical record of Patient ID # 1 contained the results of an x-ray and CT scan, performed following the identification of an injury of unknown origin.

Findings included:

Record review on 6/21/2022 of the medical record of Patient # 1 showed she was a 54-year-old female patient admitted involuntarily to the facility on 11/18/2019. Patent 1 # was admitted for escalating aggressive behaviors at her group home. Patient # 1 had a documented history of Schizophrenia and mild intellectual developmental disability [IDD]. Per admission transfer report: "she started kicking, hitting people, and started hitting her head on the wall."

Review of a nursing progress note dated 11/19/2019 , showed " pt still at 'Ben Taub Hospital (BTGH) with female escort at shift change.. contacted the nurse taking care of the patient and she reported that a CT of the head was done. X-ray of both forearms and hand was done.. waiting results...".

Review of attending MD progress note, dated 11/20/2019 showed: "pt found to have right ulnar fracture upon evaluation at BTGH for head injury due to self-injurious behaviors. Unknown how fracture occurred. Pt wish bruising with history of self-injurious behaviors.

Review of "Discharge Summary" , dated 12/06/2019 read: On Day 3, pt was observed by staff to have thrown self to floor. She was treated with emergency medications for acute agitation and risk of harm to self and others....she was transferred to BTGH, as pt was noted to have laceration above right eye ( to assess need for sutures). She was found to have a fracture of right ulnar styloid process and she was placed in brace on right wrist..." Patient # 1 returned to the facility as an inpatient following the assessment at BTGH .

Continued review of Patient #1's medical record failed to show the results from the x-rays and CT scan done at BTGH on 11/19/2019. The facility was unable to locate the x-ray and CT results for surveyor review.

During an interview on 6/22/2022 with Staff A, Director of Performance Improvement, she stated the reports should have been in the record. Staff A said the facility had changed electronic medical record systems since then. It was possible those portions of Patient# 1's record did not get migrated over.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a clean & sanitary manner and free of flies.

Findings included:

Record review of Texas Food Establishment Rules (TFER) October 2015 showed:

228.186 (b): cleaning frequency: the physical facilities shall be cleaned as often as necessary to keep them clean.

228.186 (k): controlling pests: the presence of pests shall be controlled to eliminate their presence by routinely inspecting incoming shipments of food; routinely inspecting the premises for evidence of pests; and using methods to control..such as trapping or other devices.

Observation on 6/23/2022 at 9:30 AM in the facility kitchen showed:

* multiple flies noted buzzing around surveyor- several times;

* one opened box of bananas stored directly on the floor;

* multiple empty cardboard boxes stored in a pile on the floor;

* three (3) large bags of soiled linen stacked in the corner , next to a full bucket and mop;

* over-flowing trash cart; three (3) large bags of trash on the floor next to the cart.

* kitchen floor noted to be dirty and grimy under several kitchen stainless work tables.

During an interview with Staff K, Dietary Director , at the time of observation, he was asked why the kitchen looked like this? Staff K said "We have been busy with a lot of catering lately."