Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
280% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 1
Dec 22, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with pharmaceutical service requirements, specifically the management and documentation of controlled drugs.
Findings
The facility failed to establish a system of records for receipt and disposition of controlled drugs in sufficient detail to enable accurate reconciliation for one resident. The facility did not document the receipt and disposition of Resident #1's Oxycodone HCl medication, posing a risk for inaccurate medication reconciliation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication dosage: 5
Medication administration frequency: 12
Date of medication discontinuation: Nov 18, 2025
Date of medication order: Nov 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Stated medications left by discharged residents should be signed for and documented by the Director of Nursing | |
| RN B | Indicated all narcotics and discharge records were managed by the Director of Nursing and must be logged | |
| LVN A | Noted medications left with him would be reported to the Director of Nursing immediately for tracking and logging | |
| Medication Aide A | Explained protocol for disposing of medications left by discharging residents | |
| Director of Nursing | Director of Nursing | Acknowledged the issue surrounding undocumented oxycodone and inability to provide a log for medications left behind by residents |
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 1, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory standards related to food service, nutrition, and safety in the nursing home facility.
Findings
The facility was found deficient in ensuring food was prepared to conserve nutritive value and flavor, specifically using water instead of broth to puree foods, which could reduce nutritional content. Additionally, the facility failed to properly store, label, and date food items, and staff did not consistently wear required hairnets or beard guards, posing risks for foodborne illness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure food was palatable, attractive, and at a safe and appetizing temperature; specifically, water was used to puree chicken tenders and broccoli instead of broth, potentially diluting nutritional value. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards; food items were uncovered, unlabeled, undated, and staff did not wear hairnets or beard guards. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Residents Affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CK | Cook | Named in deficiency related to improper pureeing of food using water |
| DM | Dietary Manager | Responsible for training staff and managing food preparation; acknowledged deficiencies |
| RD | Registered Dietitian | Provided guidance on proper food preparation and monitored kitchen practices |
| ADM | Administrator | Oversaw facility expectations and policies related to food service and staff training |
| MS | Maintenance Staff | Observed not wearing hairnet or beard guard in kitchen area |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 29, 2025
Visit Reason
The inspection was conducted following a complaint regarding a resident (Resident #1) who spilled hot liquid on her leg, resulting in a second-degree burn. The investigation aimed to assess the facility's safety measures to prevent accident hazards related to hot liquids.
Findings
The facility failed to ensure that Resident #1's environment was free from accident hazards, resulting in a second-degree burn from spilled hot water. Staff training on hot beverage safety was documented, but no formal hot liquid assessment was in place. The resident received appropriate wound care and treatment orders.
Complaint Details
The complaint investigation was substantiated. Resident #1 spilled hot water on her lap on 09/21/2025, causing a second-degree burn. The incident was reported, and appropriate notifications and wound care were provided. Staff interviews confirmed training on hot beverage safety but no formal hot liquid assessment was implemented.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident sustaining a second-degree burn from spilled hot liquid. | Level of Harm - Actual harm |
Report Facts
Temperature of spilled water: 180
Date of incident: Sep 21, 2025
Date of wound care note: Sep 23, 2025
Date of physician's order: Sep 25, 2025
Training date: 202508
Upcoming training date: Oct 1, 2025
BIMS score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Interviewed regarding training on handling hot beverages and safety protocols |
| CNA B | Certified Nursing Assistant | Interviewed regarding commitment to resident safety and training on beverage temperatures |
| RN A | Registered Nurse | Interviewed about training on abuse and neglect and safe preparation and serving of hot beverages |
| DON | Director of Nursing | Interviewed about staff training, incident involving Resident #1, and facility policies on hot beverage safety |
| PA-C - 1 | Physician Assistant | Signed wound care notes for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 1, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify the resident's physician and nurse practitioner about a malfunctioning diabetic insulin pump for Resident #1, which led to irregular blood sugar readings and potential health risks.
Findings
The facility failed to notify the NP promptly when Resident #1's insulin pump malfunctioned, failed to train nursing staff on the pump, and lacked parameters for notifying the NP about abnormal blood sugar readings. These failures resulted in an Immediate Jeopardy that was removed after corrective actions, but the facility remained at a level of no actual harm while evaluating corrective measures.
Complaint Details
The complaint investigation found that the facility did not notify the NP when Resident #1's diabetic pump malfunctioned in July 2025, leading to sporadic out-of-range blood sugar readings and symptoms such as dizziness, nausea, and sweatiness. Immediate Jeopardy was identified on 07/30/25 and removed on 08/01/25 after corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to immediately notify the resident's physician and NP of significant changes related to Resident #1's malfunctioning insulin pump. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure nursing staff were trained on Resident #1's insulin pump and aware of insulin dosage. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to have parameters in place for notifying NP when blood sugar readings were abnormal. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Blood sugar readings out of normal range: 7
Residents with diabetes reviewed: 22
Residents sent to MD for order review: 3
Nursing staff in-serviced: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Interviewed nurse familiar with Resident #1 who reported concerns about insulin pump and blood sugar monitoring. | |
| RN B | Interviewed nurse who was in-serviced on blood sugar rechecking and notification procedures. | |
| RN C | Interviewed nurse who attended in-service on insulin pumps and glucose monitoring. | |
| Director of Nursing | Director of Nursing | Responsible for education, corrective actions, and monitoring related to the insulin pump deficiency. |
| ADM | Administrator | In-serviced on notification of changes and involved in corrective action plans. |
| Resident #1 | Resident affected by the insulin pump malfunction and interviewed regarding symptoms and care. | |
| Resident #1's NP | Nurse Practitioner | Ordered discontinuation of insulin pump and sliding scale after concerns about pump malfunction. |
Inspection Report
Routine
Deficiencies: 10
Jun 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, financial management, activities, pharmaceutical services, food service, call light systems, and pest control at Deer Creek Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to honor resident council grievances, failure to allow timely access to resident funds, inadequate activities programming for certain residents, failure to provide ordered medical treatments, expired medications and supplies in the medication room, unpalatable and poorly prepared food, inadequate snack availability, poor kitchen sanitation, improperly accessible call light systems in resident bathrooms, and ineffective pest control resulting in presence of flies and gnats.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to consider and respond to resident council grievances regarding food and other concerns from January through June 2025. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents had timely access to petty cash funds including weekends. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide ongoing activities to meet the needs of non-ambulatory Resident #7, including lack of in-room activities during May and June 2025. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #20 had elastic compression bandages applied as ordered, resulting in untreated edema and pain. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to remove expired medications and medical supplies from the medication room, including expired Albuterol Sulfate inhalation solution and sterile water. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve palatable, attractive, and properly prepared food; pureed and regular texture meals lacked flavor, proper consistency, garnishment, and condiments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide suitable and nourishing snacks at appropriate times and maintain adequate snack reserves in nourishment rooms on 100 and 200 halls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain kitchen sanitation including cleaning of ice machine, juice dispenser, microwave, walk-in refrigerator, and kitchen floors; failed to ensure proper food storage, labeling, and hair restraint use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident bathroom call light systems were accessible to residents lying on the floor; 56 of 61 rooms had push button call lights without pull strings. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective pest control program; flies and gnats were observed in resident rooms, dining rooms, and kitchen. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident Council grievances: 10
Resident rooms with inaccessible call light pull strings: 56
Expired medication and supplies: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CK K | Cook | Observed pureeing foods without measuring food thickener and not tasting food after preparation |
| DM | Dietary Manager | Responsible for kitchen operations and training; acknowledged issues with pureed food preparation and kitchen sanitation |
| RD | Registered Dietitian | Provided input on food quality and kitchen practices |
| RECP | Resident Engagement/Concierge Personnel | Responsible for petty cash funds; confirmed no weekend access |
| ADM | Administrator/Administrator Manager | Discussed grievance follow-up process and petty cash policies |
| DON | Director of Nursing | Discussed grievance impact, medication administration, and kitchen sanitation |
| LVN D | Licensed Vocational Nurse | Responsible for checking expired medications; reported uncertainty about effects of expired supplies |
| LVN E | Licensed Vocational Nurse | Responsible for checking expired medications; reported uncertainty about effects of expired supplies |
| MA | Medication Aide | Responsible for checking expired medications; reported uncertainty about effects of expired supplies |
| MS | Maintenance Supervisor | Responsible for pest control and ice machine maintenance |
| RN G | Registered Nurse | Discussed call light accessibility concerns |
| CNA H | Certified Nursing Assistant | Discussed call light accessibility concerns |
| Maintenance Director | Discussed call light placement and repair responsibilities |
Inspection Report
Annual Inspection
Deficiencies: 2
Jun 11, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, focusing on wound care treatments and pressure ulcer prevention for residents at the facility.
Findings
The facility failed to ensure proper documentation and completion of wound care treatments for two residents, Resident #1 and Resident #2, on multiple occasions in May and June 2025, potentially placing residents at risk of inadequate care and health decline.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to document wound care treatments for Resident #1's right calf (11 times) and Resident #2's left and right heels (4 times) according to physician orders in May and June 2025. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #2, including missed wound care treatments on multiple dates in May and June 2025. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed wound care treatments for Resident #1: 11
Missed wound care treatments for Resident #2: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ADM | Stated expectation that wound care be completed and documented accurately; administrative team responsible for monitoring documentation | |
| LVN A | Explained documentation practices and implications of incomplete or missing wound care documentation | |
| RN B | Stated nurses were expected to complete and document treatments; blank documentation indicated treatment was not completed | |
| DON | Expected nurses to follow physician orders and document treatments; noted unfamiliarity with monitoring systems due to recent hire |
Inspection Report
Complaint Investigation
Deficiencies: 3
May 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to immediately notify the physician of a significant change in a resident's condition, specifically related to surgical site infection and wound care.
Findings
The facility failed to ensure timely notification and appropriate treatment for Resident #1's surgical site infection, resulting in an Immediate Jeopardy (IJ) that was later removed. The resident's incision dehisced and became infected due to lack of monitoring and communication. Corrective actions and staff education were implemented to address systemic issues.
Complaint Details
The complaint investigation found that Resident #1's surgical site was not properly monitored or communicated to the NP or physician, leading to infection and hospitalization. The facility was cited for immediate jeopardy due to these failures.
Severity Breakdown
Immediate jeopardy: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to immediately consult with the resident's physician when there was a significant change in condition related to surgical site infection. | Immediate jeopardy |
| Failure to ensure the nurse practitioner was notified of swelling and tenderness to Resident #1's incision sites on 02/10/25. | Immediate jeopardy |
| Failure to ensure surgical sites were assessed and determined healed by NP or MD. | Immediate jeopardy |
Report Facts
Staples on Resident #1: 18
BIMS score: 13
Residents assessed in skin sweep: 72
Residents with skin integrity issues: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Nurse who sent Resident #1 to hospital and assessed surgical site drainage |
| ADON H | Assistant Director of Nursing and Wound Care Nurse | Provided wound care and stated expectations for notification of surgical sites |
| ADON G | Assistant Director of Nursing | Oversaw 100 hall and stated expectations for notification of wound changes |
| RN E | Registered Nurse | Completed skin assessment and stated nurses cannot determine if wound is healed |
| LVN D | Licensed Vocational Nurse | Completed skin assessment and stated surgical sites were healed |
| Resident #1's NP | Nurse Practitioner | Responsible for assessing surgical sites and ordering treatment |
| CNA F | Certified Nursing Assistant | Reported swelling and drainage of Resident #1's surgical sites |
| DON | Director of Nursing | Provided interviews regarding wound care and notification expectations |
| Administrator | Administrator | Educated on policies and corrective actions |
| Area President | Area President | Responsible party for education and corrective actions |
| Chief Nursing Officer | Chief Nursing Officer | Responsible party for education and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the improper storage and handling of controlled drugs, specifically Hydrocodone and Valium, for Resident #1 at Deer Creek Nursing and Rehabilitation.
Findings
The facility failed to ensure that controlled drugs were stored in locked compartments and properly logged, resulting in the loss of Hydrocodone medication for Resident #1. Staff did not follow controlled drug policies, leading to missing medication and improper documentation. The investigation revealed staff errors and policy violations, with one nurse terminated and others retrained.
Complaint Details
The complaint investigation revealed that on 10/23/24, Hydrocodone prescribed for Resident #1 was missing from the medication cart. The family confirmed the medication was never returned. Interviews with nursing staff revealed improper storage and documentation of controlled drugs. The night nurse failed to communicate about the medications during shift change. The facility conducted a drug test; one nurse refused testing and was terminated. Other staff received additional training.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure storing all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for controlled drugs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure one bottle of Hydrocodone and one bottle of Valium of Resident #1 were stored in a separately locked, permanently affixed compartment for controlled drugs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to enter controlled drugs into the controlled drug logbook as soon as received and failure to store them properly in the controlled drug locker. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Tablets of Hydrocodone: 28
Date of missing medication incident: Oct 23, 2024
Date of facility investigation report: Nov 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Admission Nurse | Admitted Resident #1, stored controlled drugs improperly, failed to enter drugs into logbook. |
| RN B | Night Nurse | Received notification about controlled drugs but failed to communicate during shift change; refused drug test and was terminated. |
| MA C | Medication Aide | Discovered Valium on med cart, reported to charge nurse, witnessed logbook entry. |
| RN D | Day Shift Charge Nurse | Entered Valium into controlled drug logbook, reported incident to DON, conducted search for missing Hydrocodone. |
| LVN E | Licensed Vocational Nurse | Administered medications on 10/23/24, contacted family about missing Hydrocodone. |
| DON | Director of Nursing | Led investigation, confirmed policy violations, oversaw staff drug testing and training. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse, neglect, or injury of unknown origin involving Resident #1, and concerns about the adequacy of treatment and care following unwitnessed falls.
Findings
The facility failed to report an injury of unknown origin (hematoma) to Resident #1 within the required timeframe and did not conduct all necessary neurological checks or complete a skin assessment after unwitnessed falls. These failures could place residents at risk of abuse, neglect, uncontrolled pain, injury, and hospitalization.
Complaint Details
The complaint investigation focused on allegations that the facility failed to report an injury of unknown origin (hematoma) to Resident #1 within 24 hours and failed to conduct necessary neurological checks and skin assessments after unwitnessed falls. The facility did not report the hematoma to the State Survey agency, attributing it to a fall. Interviews with nursing staff and the nurse practitioner revealed inconsistent documentation and incomplete neurological evaluations. The facility's Abuse and Neglect Policy did not specify reporting requirements to HHSC.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse, neglect, or injury of unknown origin involving Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care by not conducting all necessary neurological checks after unwitnessed falls and not completing a skin assessment after discovery of hematoma. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Neurological evaluations: 24
Neurological checks frequency: 72
Skin tear size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Notified of hematoma, assessed Resident #1, administered PRN morphine, and acknowledged incomplete neurological checks. |
| LVN D | Licensed Vocational Nurse | Worked during the fall shift, reported no injuries noted, and discussed neurological checks. |
| RN C | Registered Nurse | Assessed Resident #1 after fall, did not notice vaginal area injury, attributed hematoma to fall. |
| NP | Nurse Practitioner | Assessed Resident #1, ordered x-rays, and associated hematoma with fall. |
| DON | Director of Nursing | Notified of hematoma, conducted in-service on neurological assessments, and stated expectations for care. |
| AADM | Assistant Administrator | Stated hematoma was not reported to HHSC because it was associated with a fall. |
Inspection Report
Routine
Deficiencies: 10
Apr 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, medication administration, call light accessibility, activities of daily living assistance, environmental safety, feeding tube care, food service safety, garbage disposal, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity with catheter privacy bags, improper medication self-administration practices, call lights not within reach for some residents, inadequate nail care for dependent residents, unsecured housekeeping chemicals posing safety risks, improper feeding tube medication administration, food safety violations including improper labeling and temperature control, unclean dumpster areas, and lapses in infection control practices such as hand hygiene and catheter tubing management.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with respect and dignity by not using privacy bags on Foley catheter drainage bags for Resident #16. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #171 did not have medications prescribed by physician in her room and was not assessed for self-administration capability. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure call lights were within reach for Residents #46 and #173. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate nail care for Residents #29, #46, and #174, resulting in dirty nails with blackish/brownish substance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to secure chemicals on housekeeping carts, with missing or broken locks, exposing residents to potential injury or poisoning. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly check for residual volume before administering medications via gastrostomy tube for Resident #63. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, distribute, and serve food in accordance with professional standards including unlabeled and undated food items, improper hot food temperatures, unwashed blender, and kitchen drains with standing water. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly dispose of garbage and maintain dumpster areas free from trash and debris. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective infection prevention and control program including lapses in hand hygiene during feeding and catheter tubing dragging on the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to enforce policy prohibiting long artificial fingernails among direct care staff, posing infection control risks. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity issues: 2
Residents reviewed for medication administration: 2
Residents reviewed for call light accessibility: 14
Residents reviewed for quality of life: 8
Housekeeping carts inspected: 3
Residents reviewed for accidents and supervision: 8
Residents reviewed for feeding tubes: 1
Kitchens reviewed for sanitation: 1
Dumpsters reviewed for garbage disposal: 3
Residents reviewed for infection control: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to catheter care and feeding tube medication administration |
| LVN B | Licensed Vocational Nurse | Named in interviews regarding feeding tube procedures and hand hygiene |
| ADON | Assistant Director of Nursing | Named in interviews regarding catheter care and infection control |
| CNA E | Certified Nursing Assistant | Named in interviews regarding catheter care |
| Dietary Supervisor | Dietary Supervisor | Named in interviews and observations related to food safety and dumpster maintenance |
| Housekeeper G | Housekeeper | Named in observations and interviews regarding housekeeping cart locks |
| Housekeeper H | Housekeeper | Named in observations and interviews regarding housekeeping cart locks |
| Maintenance Supervisor | Maintenance Supervisor | Named in interviews regarding housekeeping cart locks and kitchen drain issues |
| Administrator | Facility Administrator | Named in multiple interviews regarding facility policies and expectations |
| DON | Director of Nursing | Named in interviews regarding hand hygiene and infection control |
| CNA F | Certified Nursing Assistant | Named in interviews regarding hand hygiene and nail care |
| Med Aide C | Medication Aide | Named in observations and interviews regarding hand hygiene and artificial fingernails |
| Med Aide D | Medication Aide | Named in interviews regarding artificial fingernails |
| CK I | Cook | Named in observation regarding blender sanitation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 27, 2023
Visit Reason
The inspection was conducted following a complaint regarding neglect of Resident #1, who was left alone in a hot motorized van for an extended period, causing distress and potential harm.
Findings
The facility failed to ensure Resident #1's safety and comfort when she was left alone in a hot van with the doors open for 14 minutes, causing dizziness, thirst, panic, and fear of losing consciousness. This neglect placed residents at risk of heat exhaustion, dehydration, and emotional distress.
Complaint Details
The complaint investigation revealed that Resident #1 was left in a hot van for approximately 14 minutes with the doors open, causing her to feel dizzy, thirsty, panicked, and fearful of fainting. Resident #1 reported the incident and declined to file a grievance. Interviews with staff and family members confirmed the incident and the facility's failure to ensure resident safety during transportation.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect Resident #1 from neglect by leaving her alone in a hot motorized van with doors open for 14 minutes, causing physical and emotional harm. | Level of Harm - Actual harm |
Report Facts
Duration resident left in van: 14
Temperature outside: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MKD (Medication Aide/Driver) | Transported Resident #1 and left her in the van during the incident | |
| ADM (Administrator) | Spoke with Resident #1 after the incident and was notified by MKD | |
| DON (Director of Nursing) | Approved MKD to leave Resident #1 in the van and was interviewed about the incident | |
| MAINTD (Maintenance Director) | Interviewed regarding van AC and conducted temperature observation | |
| Receptionist | Received call from Resident #1 during the incident | |
| Resident #1's NP (Nurse Practitioner) | Provided medical opinion on risks of heat exposure |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 28, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to consider and act upon the grievances and recommendations of the resident council and issues related to food storage and safety.
Findings
The facility failed to maintain proper documentation and response procedures for resident council grievances, resulting in residents feeling unheard and concerns unaddressed. Additionally, the facility failed to properly label, date, and store food items in the kitchen refrigerator and failed to ensure mechanically altered hot foods reached safe temperatures, posing a risk of foodborne illness.
Complaint Details
Complaint investigation revealed residents' concerns about lack of response to grievances, changes to common areas, temperature and odors in the facility, and staff communication. Food safety concerns included improper labeling, dating, and temperature control of food items.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to consider views of resident or family group and act promptly on grievances; no procedure to maintain documentation of meeting notes or address concerns. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute, and serve food in accordance with professional standards; food items in walk-in refrigerator were not properly covered, labeled, or dated; mechanically altered hot foods not heated to required temperature. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents interviewed: 10
Grievances related to living room change: 2
Temperature of mechanically altered hot bread: 98
Dates on food items: 13
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