HospitalInspections.org

Please verify the owner (governing body) of the facility.

Department of Health and Human Services Commission received a letter from Erin Bosley dated 12-16-2021 stating that "transaction involving Cobalt Rehabilitation Houston Heights & Cobalt Rehabilitation Houston Heights - West Houston (collectively, the "Hospital"). Effective November 15, 2021, PAM Cubed LLC (an affiliate of Post Acute Medical, LLC) acquired 100% of the indirect ownership interests in the Hospital through a stock/equity purchase agreement."

The facility license shows Cobalt Rehabilitation Houston Heights, license # 100478 and CMS provider # 673072 as owner of the licensed hospital at 1917 Ashland Street, 4th floor, Houston TX 77008.






Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to provide safe access to a patient. Door swings into the patient toilet room and doorframe has doorstops at rehab gym's patient toilet. Health department accepts patient toilet doors swinging out if that door's frame has no stop and emergency hardware where the door can swing both into the room for normal functions and out from the room in case of emergencies.
"Emergency access. Rooms containing bathtubs, showers, and water closets, intended for patient use shall be provided with at least one door having hardware which will permit access from the outside in any emergency. Door leaf width of such doors shall not be less than 36 inches." - §133.162 (d)(2)(A)(viii)





Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to provide notification to nurse staff for patient assistance. Dome light was missing at rehab gym's patient toilet.
"Activation of the system will sound a distinct audible signal at the nursing unit's nurses station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door." - §133.162 (d)(5)(L)(iii)





Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to provide safe environment to a patient. Patient bathroom is supplied by normal branch, and it shall be powered by the critical branch of the EES.
"A ceiling-mounted fixture shall be provided in patient bathrooms where the lighting fixture above the lavatory does not provide adequate illumination of the entire bathroom. Some form of fixed illumination shall be powered from the critical branch" §133.163 (t)(5)(C)(iii)(IV)





Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to provide safe dietary environment. Freezer is missing alarm.
"Coolers, refrigerators, and freezers shall be thermostatically controlled to maintain desired temperature settings in increments of two degrees or less. Interior temperatures shall be indicated digitally and visible from the exterior. Controls shall include audible and visible high and low-temperature alarm. The time of alarm shall be automatically recorded." - §133.163 (e)(1)(D)(ii)





Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to provide safe environment for non-air borne isolation patients and staff.
The isolation room's hardware set does not have a closure at door from ante room into patient isolation room or at the ante room from the corridor.
"A door(s) from an anteroom to an airborne infection isolation room(s) and a door(s) from an egress corridor into an anteroom shall be provided with a self-closing device(s). When an isolation room does not have an anteroom, the door from the egress corridor into the isolation room shall be provided with a self-closing device." - §133.163(t)(1)(C)(iv)



Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility did not maintain a safe environment for its technology. IT room is not secured from unauthorized people. It is not in direct sight of a staff location.

Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to maintain an exit sign. Exit sign is not lit in the egress corridor, by the doctor office.
NFPA 99: 4.4.2.2.2.2 The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch
Also, International Fire Code 604.6

Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to maintain its rated room. Rated door did not latch at soiled utility room.
"Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated. The doors shall be a minimum ¾ hour fire rated doors set in rated frames. With that classification, the door's hardware, including door closers device and latching hardware, must meet the requirement for storage rooms." - NFPA 101: 18.3.2.

Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to maintain its sprinkler system. Sprinkler escutcheon plate is missing at isolation bathroom.
"Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed assembly." - NFPA 13: 6.2.6.4.4

Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to maintain its egress route. Astragal was missing at double doors' meeting edges at patient bedroom 4219.
"Corridor walls shall form a barrier to limit the transfer of smoke" - NFPA 101: 18.3.6.2.1
"Doors shall be provided with positive latching hardware." - NFPA 101: 18.3.6.3.5

Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to maintain its electrical system. A j-box is not covered by faceplate in medical records room.
"All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110." - NFPA 70: 314.28 (2)(C)




Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to maintain its electrical system. Normal and emergency light switches appeared to be in one box at multiple locations throughout the facility. Confirm that all locations have a metal separation or are in two different junction boxes.
"The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Where general care locations are served from two separate transfer switches on the emergency system in accordance with 517.18(A), Exception No. 3, the general care circuits from the two separate systems shall be kept independent of each other.
Where critical care locations are served from two separate transfer switches on the emergency system in accordance with 517.19(A), Exception No. 2, the critical care circuits from the two separate systems shall be kept independent of each other.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring complies with one of the following:
(1)?Is in transfer equipment enclosures
(2)?Is in exit or emergency luminaires supplied from two sources
(3)?Is in a common junction box attached to exit or emergency luminaires supplied from two sources
(4)?Is for two or more emergency circuits supplied from the same branch and same transfer switch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system." - NFPA 70: 517.30 (C)(1)

Based on observations during the survey walk of the facility on 1/13/2022, accompanied by the Director of Nursing, the facility failed to maintain its ceilings. Ceiling tiles are missing at electrical room and IT room. Fire may spread rapidly through openings in ceilings. Ceiling tiles are part of your fire resistance-rated ceiling.
"Floor, wall and ceiling penetrations by pipes, ducts, and conduits or any direct opening shall be tightly sealed to minimize entry of dirt particles, rodents and insects. Joints of structural elements shall be similarly sealed." - §133.162(d)(2)(B)(v)
Also, International Fire Code 703.1