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Deficiency Category | Inspection Date: 11/20/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 10/11/23 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 8/31/22 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: | 11/20/24Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | 11/20/24Read 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. |
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. | 11/20/24 | 11/21/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 11/20/24 | 11/21/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide care or services that was trauma informed and/or culturally competent. | 11/20/24 | 11/21/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 11/20/24 | 11/21/24 | 3 - 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. | 11/20/24 | 11/21/24 | 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 each resident receives an accurate assessment. | 11/20/24 | 11/21/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 11/20/24 | 11/21/24 | 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) |
---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 11/20/24 | 11/21/24 | 3 - 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. | 11/20/24 | 11/21/24 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 11/20/24 | 11/21/24 | 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) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 11/20/24 | 11/21/24 | 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 that residents are free from significant medication errors. | 11/20/24 | 11/21/24 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 10/11/23Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | 8/18/23Read 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: |
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 each resident is free from the use of physical restraints, unless needed for medical treatment. | 8/18/23 | 8/18/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 8/18/23 | 8/18/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 8/18/23 | 3/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 8/18/23 | 8/18/23 | 4 - Immediate jeopardy to resident health or safety | 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 care and assistance to perform activities of daily living for any resident who is unable. | 10/11/23 | 10/30/23 | 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. | 10/11/23 | 10/18/23 | 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. | 10/11/23 | 11/9/23 | 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. | 10/11/23 | 11/9/23 | 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) |
---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 10/11/23 | 10/12/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/11/23 | 10/12/23 | 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. |
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. | 10/11/23 | 10/13/23 | 2 - Minimal harm or potential for actual harm | Few |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 10/11/23 | 11/6/23 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 8/31/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | No complaint inspections |
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23 | 1/17/23Read the full report (PDF) 4/13/22Read 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. |
No Infection Control Deficiencies were found during this inspection period. |
No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
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. |
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 safe, appropriate pain management for a resident who requires such services. | 11/20/24 | 11/21/24 | 3 - Actual harm | Some |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | 8/18/23 | 8/18/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 8/18/23 | 8/18/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 8/18/23 | 3/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 8/18/23 | 8/18/23 | 4 - Immediate jeopardy to resident health or safety | Few |
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |