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| Deficiency Category | Inspection Date: 6/6/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 4/13/23 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 2/10/22 Complaint Reporting Period: 3/1/22 - 2/28/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 6/6/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | 4/10/24Read the full report (PDF) 3/12/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Texas: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 6/6/24 | 7/7/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/10/24 | 5/1/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/6/24 | 9/7/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 1/8/25 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 1/8/25 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 6/6/24 | 7/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 1/8/25 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 3/12/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 3/12/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 9/6/24 | 9/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 1/8/25 | 2 - Minimal harm or potential for actual harm | Few |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 3/12/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 4/13/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | 1/29/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24 | 1/29/24Read the full report (PDF) 1/18/24Read the full report (PDF) 10/3/23Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Texas: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| No Quality of Life and Care Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 4/13/23 | 5/10/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | 1/29/24 | 2/21/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| No Resident Rights Deficiencies were found during this inspection period. |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 2/10/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | 12/29/22Read the full report (PDF) 10/28/22Read the full report (PDF) 10/18/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23 | 2/28/23Read the full report (PDF) 12/29/22Read the full report (PDF) 10/28/22Read the full report (PDF) 9/26/22Read the full report (PDF) 8/17/22Read the full report (PDF) 3/22/22Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Texas: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 10/28/22 | 11/25/22 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 7/8/22 | 8/5/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 2/10/22 | 3/7/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives an accurate assessment. | 2/10/22 | 3/7/22 | 2 - Minimal harm or potential for actual harm | Few |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | 10/28/22 | 11/25/22 | 2 - Minimal harm or potential for actual harm | Some |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| No Resident Rights Deficiencies were found during this inspection period. |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 12/29/22 | 2/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 10/18/22 | 11/8/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 2/10/22 | 3/7/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 6/1/22 | 7/5/22 | 2 - Minimal harm or potential for actual harm | Few |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 2/10/22 | 3/7/22 | 2 - Minimal harm or potential for actual harm | Few |
Have policies on smoking. | 2/10/22 | 3/7/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Administration Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 6/6/24 | 7/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/10/24 | 5/1/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/6/24 | 9/7/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 1/8/25 | 2 - Minimal harm or potential for actual harm | Some | |
Provide and implement an infection prevention and control program. | 1/8/25 | 2 - Minimal harm or potential for actual harm | Few | |
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 6/6/24 | 7/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 1/8/25 | 2 - Minimal harm or potential for actual harm | Some | |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 3/12/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 3/12/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 9/6/24 | 9/7/24 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 1/8/25 | 2 - Minimal harm or potential for actual harm | Few | |
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. | 3/12/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Some |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | 1/29/24 | 2/21/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 10/28/22 | 11/25/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 7/8/22 | 8/5/22 | 2 - Minimal harm or potential for actual harm | Few |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | 10/28/22 | 11/25/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 12/29/22 | 2/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 10/18/22 | 11/8/22 | 2 - Minimal harm or potential for actual harm | Some |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 6/1/22 | 7/5/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 10/28/22 | 11/25/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 7/8/22 | 8/5/22 | 2 - Minimal harm or potential for actual harm | Few |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | 10/28/22 | 11/25/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 12/29/22 | 2/1/23 | 2 - Minimal harm or potential for actual harm | Few |