Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 2
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with food safety standards in the kitchen, focusing on proper storage, preparation, and handling of food.
Findings
The facility failed to store semi-thawed meat properly, causing liquid to drip onto the freezer floor, and failed to store dry goods off the floor. These failures posed a risk of food-borne illness to residents. Interviews confirmed improper thawing and storage practices, and the facility planned re-education for dietary staff.
Deficiencies (2)
Failed to ensure semi-thawed meat was stored properly, causing liquid to drip onto the freezer floor.
Failed to ensure dry storage food was stored properly and off the floor.
Report Facts
Weight of bag of onions: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food storage and thawing procedures | |
| Administrator | Interviewed regarding expectations for thawing and food storage |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory standards related to resident care, specifically focusing on baseline care plans and respiratory care for residents.
Findings
The facility failed to develop and implement adequate baseline care plans for residents, including failure to update care plans with necessary treatments such as oxygen and sleep apnea care. Additionally, the facility failed to provide safe and appropriate respiratory care, including failure to change and date oxygen tubing and equipment per policy, which could place residents at risk of respiratory infections and improper care.
Deficiencies (3)
Failed to update Resident #7's baseline care plan to include oxygen treatment, sleep apnea treatment, and assessments of O2 sats every shift.
Failed to ensure residents' nasal cannula oxygen tubing and respiratory equipment were changed and dated per facility policy and physician orders.
Failed to document Resident #7's diagnosis of COPD and oxygen orders on the care program.
Report Facts
Residents reviewed for baseline care plan: 3
Residents reviewed for respiratory care: 7
Residents affected by respiratory care deficiencies: 5
Oxygen flow rate: 3
Oxygen flow rate: 2
Fall incident time: 1600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN P | Registered Nurse | Admitted to placing white tape on Resident #3's oxygen tubing that was on the floor and stated responsibility for changing and dating tubing. |
| LVN T | Licensed Vocational Nurse | Documented Resident #7's admission progress note including oxygen use and condition. |
| LVN C | Licensed Vocational Nurse | Documented Resident #7's progress note including oxygen and respiratory status. |
| ADON | Assistant Director of Nursing | Stated responsibility for monitoring nursing tasks and baseline care plans. |
| DON | Director of Nursing | Stated responsibility for monitoring admission care plans and nursing staff compliance with respiratory care policies. |
| Administrator | Facility Administrator | Stated nursing responsibility for changing tubing and overseeing respiratory care policy compliance. |
| MDS Coordinator | MDS Coordinator | Discussed MDS assessment and significant change notifications related to Resident #6. |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure accessible call lights for residents, failure to update care plans especially regarding hospice status, improper IV fluid administration technique, lack of informed consent and assessment for bed rails/enabler bars, improper labeling and dating of vaccines, failure to label and date food items in the kitchen, and lapses in infection control practices such as blowing on resident food and inadequate wound care precautions.
Deficiencies (7)
Facility failed to ensure call lights were accessible to residents #41 and #62.
Failed to revise Resident #15's care plan to update and remove conflicting hospice status.
Failed to ensure proper technique flushing Resident #14's midline IV catheter, risking air embolus.
Failed to obtain informed consent, assessment, and physician order for bed rails/enabler bars for Resident #40.
Failed to label and date open influenza and tuberculosis vaccine vials.
Failed to label and date prepared foods in the kitchen, risking food contamination.
Failed to maintain infection control practices: staff blew on resident #1's food and did not protect wound care area for resident #43.
Report Facts
Residents reviewed for call light accessibility: 14
Residents reviewed for care plans: 8
Residents reviewed for IV fluids: 4
Residents reviewed for bed rails/enabler bars: 3
Medication rooms reviewed for labeling: 2
Residents reviewed for infection control: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Named in improper IV flushing technique for Resident #14. |
| CNA B | Certified Nursing Assistant | Interviewed regarding call light responsibilities and bed rail hazards. |
| ADON | Assistant Director of Nursing | Interviewed regarding call light expectations and bed rail policies. |
| DON | Director of Nursing | Interviewed regarding call light expectations, bed rail policies, and vaccine labeling. |
| Nursing Scheduler | Observed and interviewed regarding blowing on resident #1's food. | |
| LVN E | Licensed Vocational Nurse | Infection control preventionist interviewed about vaccine labeling. |
| ADM | Administrator | Interviewed regarding bed rail policies and consent. |
| MDS Coordinator | Interviewed regarding care plan updates and hospice status. | |
| Social Worker | Interviewed regarding care conferences and care plan updates. | |
| Dietary Manager | Interviewed regarding food labeling and storage. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
The inspection was conducted as an annual survey of Hurst Plaza Nursing & Rehab to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were unknown.
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