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| Deficiency Category | Inspection Date: 12/13/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 10/25/23 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 8/30/22 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: | 12/13/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | 12/13/24Read 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: |
| 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. | 12/13/24 | 12/14/24 | 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) |
|---|---|---|---|---|
Assess the resident when there is a significant change in condition | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 12/13/24 | 12/14/24 | 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. | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services 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) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 12/13/24 | 12/14/24 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | 12/13/24 | 12/14/24 | 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) |
|---|---|---|---|---|
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. | 12/13/24 | 12/14/24 | 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: | 10/25/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | 9/22/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24 | 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: |
| 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) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/25/23 | 10/26/23 | 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) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 9/22/23 | 9/25/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Resident Assessment and Care Planning 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 that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 10/25/23 | 10/26/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Resident Rights 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 10/25/23 | 10/26/23 | 2 - Minimal harm or potential for actual harm | Few |
| 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: | 8/30/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | 12/14/22Read the full report (PDF) 8/30/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23 | 12/14/22Read 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. |
| 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. | 8/30/22 | 9/23/22 | 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) |
|---|---|---|---|---|
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 8/30/22 | 8/31/22 | 2 - Minimal harm or potential for actual harm | Some |
| No Nursing and Physician Services 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 12/14/22 | 12/15/22 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 8/30/22 | 8/31/22 | 2 - Minimal harm or potential for actual harm | Many |
| 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. | 8/30/22 | 9/16/22 | 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. |
| 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. | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Some |
Assess the resident when there is a significant change in condition | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 12/13/24 | 12/14/24 | 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. | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Some |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | 12/13/24 | 12/14/24 | 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. | 12/13/24 | 12/14/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 9/22/23 | 9/25/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 8/30/22 | 9/23/22 | 2 - Minimal harm or potential for actual harm | Some |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 8/30/22 | 8/31/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 12/14/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 8/30/22 | 8/31/22 | 2 - Minimal harm or potential for actual harm | 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. | 8/30/22 | 9/16/22 | 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 12/14/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |