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| Deficiency Category | Inspection Date: 5/8/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 3/31/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 1/21/22 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| 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: | 5/8/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 5/23/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | 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) |
|---|---|---|---|---|
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Some |
Respond appropriately to all alleged violations. | 5/23/24 | 5/24/24 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/23/24 | 5/24/24 | 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) |
|---|---|---|---|---|
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 5/8/24 | 5/9/24 | 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. | 5/8/24 | 5/8/24 | 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 and implement an infection prevention and control program. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Few |
| 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. | 5/8/24 | 5/9/24 | 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) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | 5/8/24 | 5/9/24 | 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. | 5/8/24 | 5/9/24 | 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. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 5/8/24 | 5/9/24 | 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) |
|---|---|---|---|---|
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 3/31/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | 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) |
|---|---|---|---|---|
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 3/31/23 | 4/1/23 | 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. | 3/31/23 | 4/1/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Infection Control 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) |
|---|---|---|---|---|
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 3/31/23 | 4/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 3/31/23 | 4/1/23 | 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. | 3/31/23 | 4/1/23 | 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) |
|---|---|---|---|---|
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 3/31/23 | 4/1/23 | 2 - Minimal harm or potential for actual harm | Some |
Keep residents' personal and medical records private and confidential. | 3/31/23 | 4/1/23 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 3/31/23 | 4/1/23 | 2 - Minimal harm or potential for actual harm | Many |
Dispose of garbage and refuse properly. | 3/31/23 | 4/1/23 | 1 - Potential for minimal 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 that residents are free from significant medication errors. | 7/2/23 | 7/3/23 | 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) |
|---|---|---|---|---|
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 3/31/23 | 4/1/23 | 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) |
|---|---|---|---|---|
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | 3/31/23 | 4/1/23 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 1/21/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 5/14/22Read the full report (PDF) 4/26/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | |
| 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) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 4/26/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 4/26/22 | 5/16/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 5/14/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 4/26/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/14/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
| 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. | 1/21/22 | 2/10/22 | 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) |
|---|---|---|---|---|
Ensure each resident receives an accurate assessment. | 4/26/22 | 5/16/22 | 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) |
|---|---|---|---|---|
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 1/21/22 | 2/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 5/14/22 | 5/16/22 | 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. | 1/21/22 | 2/10/22 | 2 - Minimal harm or potential for actual harm | Many |
| 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) |
|---|---|---|---|---|
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Some |
Respond appropriately to all alleged violations. | 5/23/24 | 5/24/24 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/23/24 | 5/24/24 | 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. | 5/8/24 | 5/9/24 | 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. | 5/8/24 | 5/8/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide and implement an infection prevention and control program. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | 5/8/24 | 5/9/24 | 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. | 5/8/24 | 5/9/24 | 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. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 5/8/24 | 5/9/24 | 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. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 5/8/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 7/2/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Some |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 4/26/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 4/26/22 | 5/16/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 5/14/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 4/26/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/14/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 4/26/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 5/14/22 | 5/16/22 | 2 - Minimal harm or potential for actual harm | Few |
| This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |