Community Healthcare of Texas

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including: the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition; and Tentative Interim Amendments (TIA) 12-1, TIA 12–2, TIA 12–3, and TIA 12–4; and, the Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. This standard was not met as evidenced by interview and observation. A tour of the IPU (inpatient unit) on 07/06/2026 revealed that the agency had not maintained the storage area containing oxygen cylinders. There was no signage on the door to the storage area indicating oxygen storage and no smoking. Additionally, this references K905: Gas and Vacuum Piped Systems – Locations containing only oxygen or medical air have doors labeled with “Medical Gases, NO Smoking or Open Flame”. Locations containing other gases have doors labeled “Positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening.” There were 6 oxygen e-tanks in total; the Vice President of Operations, who was present during the tour, stated that the tanks were full, but they were not stored in an area labeled “full”. The 6 tanks were secured in racks. There were no empty tanks present, but there was no area labeled “empty” where empty tanks would be stored. Additionally, this references K923 Gas Equipment – Cylinder and Container Storage... A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING”. Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion.” During an interview, the Vice President of Operations agreed that the signage was missing from the door into the storage area, and labels to indicate full or empty tanks were also missing. A tour of IPU (inpatient unit) on 7/6/2026 revealed that the agency had not maintained the storage area containing oxygen cylinders. There was no signage on the door to the storage area indicating oxygen storage and no smoking. There were 6 oxygen e-tanks total, Vice President of Operations who was present during the tour stated that the tanks were full but the tanks were not stored in an area labeled as “full”. The 6 tanks were secured in racks. There were no empty tanks present but there was no area labeled “empty” where empty tanks would be stored. During interview with the Vice President of Operations, she agreed that the signage was missing from the door into the storage area, and labels to indicate full or empty tanks were also missing.”

“It is required that patients in the hospice inpatient facility have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time. This standard was not met as evidenced by document review, interview and observation. In 2 of 2 (100%) visits observed at the In-Patient Unit (IPU), the agency did not ensure that patients were free from restraints. Restraints Policy, IF-50: Agency Policy, Restraints, IF-50, stated in part, “Inpatient hospice unit use restraint or seclusion on patients only to ensure the immediate physical safety of the patient and must be discontinued at the earliest possible time. All practices related to restraint or seclusion must comply with the regulations related to the use of restraint and seclusion and are only to be used after all other approaches have been exhausted. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.” IPU Visit 1: During IPU Visit 1 on 07/06/2026 with the Registered Nurse (Personnel File 7), the patient was observed to be non-responsive, bedbound, with family at the bedside. The 4 bed rails were observed in the up position. IPU Visit 2: During IPU Visit 2 on 07/06/2026 with the Registered Nurse (Personnel File 7), the patient was observed to be non-responsive, bedbound, with family at the bedside. The 4 bed rails were observed in the up position. During an interview on 07/07/2026, the Alternate Administrator stated, “We do consider all four rails up a restraint. The nurse seemed unclear that four rails are a restraint. We need to do in person training to help staff better understanding the different ways a patient may be restrained, intentionally or unintentionally.” During an interview on 07/07/2026, the IPU Registered Nurse (Personnel Record 7) (IPU Visit 1 & 2) stated, “It wasn’t my intention to use the four rails as a restraint, there was no safety risk or concern. I didn’t think about it being a restraint.””