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| Deficiency Category | Inspection Date: 3/15/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 2/1/23 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 11/10/21 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: | 3/15/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | 7/19/24Read the full report (PDF) 5/29/24Read the full report (PDF) 4/25/24Read 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) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/29/24 | 6/21/24 | 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 the activities program is directed by a qualified professional. | 3/15/24 | 4/15/24 | 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. | 3/15/24 | 4/15/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 5/29/24 | 6/21/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 3/15/24 | 4/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 3/15/24 | 4/15/24 | 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. | 3/15/24 | 4/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/29/24 | 6/21/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 5/29/24 | 6/21/24 | 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) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 3/15/24 | 4/15/24 | 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) |
|---|---|---|---|---|
Assure that each resident’s assessment is updated at least once every 3 months. | 3/15/24 | 4/15/24 | 1 - Potential for minimal harm | Some |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | 3/15/24 | 4/15/24 | 1 - Potential for minimal 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 medication error rates are not 5 percent or greater. | 3/15/24 | 4/15/24 | 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. | 3/15/24 | 4/15/24 | 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) |
|---|---|---|---|---|
Keep all essential equipment working safely. | 4/25/24 | 6/15/24 | 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. | 4/6/24 | 6/15/24 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that a working call system is available in each resident's bathroom and bathing area. | 4/25/24 | 6/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 3/15/24 | 4/15/24 | 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) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 7/19/24 | 8/5/24 | 2 - Minimal harm or potential for actual harm | Some |
| Date of last standard health inspection: | 2/1/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | 1/31/24Read 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) |
|---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 1/31/24 | 2/23/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide safe and appropriate respiratory care for a resident when needed. | 2/1/23 | 3/1/23 | 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) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 2/1/23 | 2/22/23 | 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) |
|---|---|---|---|---|
Ensure each resident receives an accurate assessment. | 2/1/23 | 3/1/23 | 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. | 2/1/23 | 3/1/23 | 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) |
|---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 1/31/24 | 2/23/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 2/1/23 | 3/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 2/1/23 | 3/1/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure residents have reasonable access to and privacy in their use of communication methods. | 2/1/23 | 3/1/23 | 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) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 1/31/24 | 2/23/24 | 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. | 2/1/23 | 3/1/23 | 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. | 2/1/23 | 3/1/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Environmental 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, quality laboratory services/tests to meet the needs of residents. | 2/1/23 | 3/1/23 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 11/10/21Read 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 | 12/7/22Read 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. |
| 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. | 11/10/21 | 1/11/22 | 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. | 11/10/21 | 1/11/22 | 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) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 5/29/24 | 6/21/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 5/29/24 | 6/21/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/29/24 | 6/21/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 5/29/24 | 6/21/24 | 2 - Minimal harm or potential for actual harm | Few |
Keep all essential equipment working safely. | 4/25/24 | 6/15/24 | 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. | 4/6/24 | 6/15/24 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that a working call system is available in each resident's bathroom and bathing area. | 4/25/24 | 6/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 7/19/24 | 8/5/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 1/31/24 | 2/23/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 1/31/24 | 2/23/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 1/31/24 | 2/23/24 | 2 - Minimal harm or potential for actual harm | Some |
| This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |