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| Deficiency Category | Inspection Date: 1/7/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 10/7/22 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 8/20/21 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: | 1/7/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 1/28/25Read the full report (PDF) 1/15/25Read the full report (PDF) 10/15/24Read the full report (PDF) 6/27/24Read the full report (PDF) 4/30/24Read 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: |
| 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 care and assistance to perform activities of daily living for any resident who is unable. | 6/6/24 | 6/12/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 6/6/24 | 6/12/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 1/7/24 | 1/8/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/28/25 | 3 - 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. | 6/27/24 | 6/30/24 | 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. | 10/15/24 | 10/15/24 | 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. | 10/15/24 | 10/15/24 | 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) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/30/24 | 5/2/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 7/3/24 | 7/10/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 4/30/24 | 5/2/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 1/15/25 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 6/6/24 | 6/12/24 | 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. | 6/27/24 | 6/30/24 | 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) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 6/6/24 | 6/12/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure medication error rates are not 5 percent or greater. | 1/7/24 | 1/8/24 | 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. | 6/6/24 | 6/12/24 | 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. | 4/30/24 | 5/2/24 | 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) |
|---|---|---|---|---|
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | 1/7/24 | 1/8/24 | 2 - Minimal harm or potential for actual harm | Many |
| Date of last standard health inspection: | 10/7/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 1/29/24Read the full report (PDF) 11/7/23Read the full report (PDF) 11/3/23Read the full report (PDF) 10/17/23Read the full report (PDF) |
| 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 care and assistance to perform activities of daily living for any resident who is unable. | 10/17/23 | 10/24/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/5/23 | 6/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 10/7/22 | 10/21/22 | 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. | 2/5/24 | 2/7/24 | 4 - Immediate jeopardy to resident health or safety | 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. | 10/7/22 | 10/21/22 | 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) |
|---|---|---|---|---|
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 10/7/22 | 10/21/22 | 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) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 11/7/23 | 11/10/23 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 10/17/23 | 10/24/23 | 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) |
|---|---|---|---|---|
Dispose of garbage and refuse properly. | 10/7/22 | 10/21/22 | 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. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | 11/3/23 | 11/8/23 | 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. | 11/3/23 | 11/8/23 | 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) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 10/7/22 | 10/21/22 | 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 that a working call system is available in each resident's bathroom and bathing area. | 1/29/24 | 2/5/24 | 2 - Minimal harm or potential for actual harm | Some |
Have policies on smoking. | 2/5/24 | 2/7/24 | 4 - Immediate jeopardy to resident health or safety | Some |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 8/20/21Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 1/11/23Read the full report (PDF) 10/7/22Read the full report (PDF) 9/15/22Read the full report (PDF) 5/25/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | 1/11/23Read the full report (PDF) 9/15/22Read 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) |
|---|---|---|---|---|
Honor each resident's preferences, choices, values and beliefs. | 5/25/22 | 7/19/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/11/23 | 3 - Actual harm | Few | |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 8/20/21 | 8/27/21 | 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. | 8/20/21 | 8/27/21 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 9/15/22 | 9/22/22 | 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. | 9/15/22 | 9/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/15/22 | 9/22/22 | 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. | 8/20/21 | 8/27/21 | 2 - Minimal harm or potential for actual harm | Few |
| 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. |
| 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. | 5/25/22 | 7/19/22 | 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 8/20/21 | 8/27/21 | 2 - Minimal harm or potential for actual harm | Many |
Dispose of garbage and refuse properly. | 8/20/21 | 8/27/21 | 2 - Minimal harm or potential for actual harm | Many |
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. | 8/20/21 | 8/27/21 | 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 8/20/21 | 8/27/21 | 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) |
|---|---|---|---|---|
Keep all essential equipment working safely. | 8/20/21 | 8/27/21 | 2 - Minimal harm or potential for actual harm | Many |
| 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 care and assistance to perform activities of daily living for any resident who is unable. | 6/6/24 | 6/12/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 6/6/24 | 6/12/24 | 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. | 1/28/25 | 3 - Actual harm | Few | |
Provide and implement an infection prevention and control program. | 6/27/24 | 6/30/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 10/15/24 | 10/15/24 | 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. | 10/15/24 | 10/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/30/24 | 5/2/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 7/3/24 | 7/10/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 4/30/24 | 5/2/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 1/15/25 | 4 - Immediate jeopardy to resident health or safety | Many | |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 6/6/24 | 6/12/24 | 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. | 6/27/24 | 6/30/24 | 2 - Minimal harm or potential for actual harm | Many |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 6/6/24 | 6/12/24 | 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. | 6/6/24 | 6/12/24 | 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. | 4/30/24 | 5/2/24 | 2 - Minimal harm or potential for actual harm | Some |
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | 1/7/24 | 1/8/24 | 2 - Minimal harm or potential for actual harm | Many |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 10/17/23 | 10/24/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/5/23 | 6/9/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 10/7/22 | 10/21/22 | 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. | 2/5/24 | 2/7/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide and implement an infection prevention and control program. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 11/7/23 | 11/10/23 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 10/17/23 | 10/24/23 | 2 - Minimal harm or potential for actual harm | Few |
Dispose of garbage and refuse properly. | 10/7/22 | 10/21/22 | 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. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | 11/3/23 | 11/8/23 | 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. | 11/3/23 | 11/8/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 10/7/22 | 10/21/22 | 2 - Minimal harm or potential for actual harm | Few |
Make sure that a working call system is available in each resident's bathroom and bathing area. | 1/29/24 | 2/5/24 | 2 - Minimal harm or potential for actual harm | Some |
Have policies on smoking. | 2/5/24 | 2/7/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Honor each resident's preferences, choices, values and beliefs. | 5/25/22 | 7/19/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 1/11/23 | 3 - Actual harm | Few | |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 9/15/22 | 9/22/22 | 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. | 9/15/22 | 9/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/15/22 | 9/22/22 | 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. | 5/25/22 | 7/19/22 | 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 safe, appropriate dialysis care/services for a resident who requires such services. | 9/15/22 | 9/22/22 | 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. | 9/15/22 | 9/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/15/22 | 9/22/22 | 2 - Minimal harm or potential for actual harm | Some |