Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 17, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medication self-administration policies and procedures, specifically to determine if residents were allowed to self-administer drugs only when clinically appropriate.
Findings
The facility failed to ensure that the interdisciplinary team determined self-administration of medication was safe for one resident and failed to prevent that resident from possessing and administering an inhaler without an assessment or physician order. This posed a risk of residents not receiving the therapeutic dose of their medications as ordered.
Deficiencies (2)
Failed to ensure the interdisciplinary team determined self-administration of medication was safe for Resident #1.
Failed to prevent Resident #1 from possessing and administering an inhaler without an assessment or physician order.
Report Facts
Residents reviewed for medication self-administration: 8
Residents affected: 1
BIMS score: 13
PRN medication usage: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Charge Nurse A | RN Charge Nurse | Interviewed regarding Resident #1's medication self-administration and MAR review |
| ADON B | Assistant Director of Nursing | Interviewed about facility policy and assessment requirements for self-administration |
| DON | Director of Nursing | Interviewed about facility policy and awareness of residents self-medicating |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 2, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding residents' rights to a safe, clean, comfortable, and homelike environment, as well as the provision of safe and appropriate respiratory care for residents.
Findings
The facility failed to maintain a safe and sanitary environment in the memory unit, including unclean shower chairs and improperly stored equipment, which posed risks to residents. Additionally, the facility did not consistently follow respiratory care protocols for two residents, including failure to properly clean, bag, and date oxygen and CPAP equipment, increasing the risk of respiratory infections.
Deficiencies (2)
Failure to ensure shower chairs and shower curtains were thoroughly cleaned and stored away from residents, staff, and visitors, and failure to discard used water bottles on the memory unit.
Failure to provide appropriate respiratory care for residents, including failure to change and date oxygen and CPAP equipment weekly and failure to bag equipment when not in use.
Report Facts
Residents affected: 5
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN-B | Licensed Vocational Nurse | Interviewed about shower chairs and environmental safety |
| DON | Director of Nursing | Interviewed about shower room construction and respiratory care practices |
| ADMIN | Administrator | Interviewed about staff responsibilities and facility policies |
| LVN A | Licensed Vocational Nurse | Interviewed about oxygen equipment maintenance and respiratory care |
| ADON | Assistant Director of Nursing | Interviewed about respiratory care protocols and equipment maintenance |
Inspection Report
Deficiencies: 2
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services and dining services regulations, including proper disposal of medications and the palatability of food and beverages served to residents.
Findings
The facility failed to properly dispose of used Fentanyl patches according to policy, posing a risk of overdose to residents. Additionally, the facility failed to provide palatable coffee to residents, which could diminish their quality of life.
Deficiencies (2)
Failure to provide pharmaceutical services including proper disposal of used Fentanyl Transdermal Patches, risking resident safety.
Failure to provide coffee that was palatable to meet the needs of residents, affecting quality of life.
Report Facts
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Named in medication error finding for improper disposal of Fentanyl patch | |
| RN B | Nurse | Assigned nurse to Resident #147, involved in interview about Fentanyl patch disposal |
| LVN C | Licensed Vocational Nurse | Showed MA A the proper process to destroy Fentanyl patch |
| ADON D | Assistant Director of Nursing | Showed MA A the proper process to destroy Fentanyl patch |
| Dietitian Consultant | Interviewed regarding coffee palatability and kitchen monitoring | |
| Dietary Manager | Interviewed regarding resident dissatisfaction with coffee | |
| DON | Director of Nursing | Interviewed about proper disposal procedures and staff training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #1 fell from a mechanical lift during transfer, resulting in a head laceration requiring staples.
Complaint Details
The complaint investigation found that CNA A transferred Resident #1 independently via mechanical lift despite knowing two staff members were required. Resident #1 fell and sustained a head laceration. CNA A was suspended, received a final written warning, and was re-trained. The facility conducted staff in-service and competency checks. The noncompliance was past noncompliance, beginning 02/21/25 and ending 03/04/25 after correction.
Findings
The facility failed to ensure adequate supervision and adherence to mechanical lift transfer protocols, as CNA A independently transferred Resident #1 without the required two staff members, causing the resident to fall and sustain injury. The facility corrected the noncompliance before the investigation began by in-servicing staff and conducting competency checks.
Deficiencies (1)
Failure to ensure residents received adequate supervision and assistive devices to prevent accidents, specifically transferring Resident #1 via mechanical lift without required staff assistance, resulting in a fall and head injury.
Report Facts
Residents affected: 1
Date of incident: Feb 21, 2025
Date noncompliance ended: Mar 4, 2025
Number of staff required for mechanical lift transfer: 2
Date of staff in-service: Feb 21, 2025
Date of final warning: Mar 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in deficiency for independently transferring Resident #1 via mechanical lift without required assistance; received final written warning and re-training |
| LVN B | Licensed Vocational Nurse | Responded to incident, called 911, and provided assistance to Resident #1 |
| Administrator | Facility Administrator | Provided statements regarding incident, corrective actions, and monitoring compliance |
Inspection Report
Deficiencies: 4
Date: May 16, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, advance directives, medication storage and labeling, and food safety standards in the facility.
Findings
The facility was found deficient in ensuring residents' dignity during feeding, honoring advance directives, securing medications, and properly storing and monitoring food brought by families. Immediate Jeopardy was identified related to failure to honor a resident's DNR order, which was later removed after corrective actions. Other deficiencies included failure to secure medications and failure to monitor and clean resident refrigerators.
Deficiencies (4)
Failure to treat Resident #30 with dignity when staff stood over the resident while feeding her.
Failure to honor Resident #71's advance directive resulting in administration of CPR contrary to DNR wishes, constituting Immediate Jeopardy.
Failure to ensure drugs and biologicals were labeled and stored properly; medication cart left unsecured and Resident #323's self-administered medications not secured.
Failure to monitor and clean Resident #5's refrigerator, including failure to monitor temperature and discard undated foods.
Report Facts
Residents reviewed for dignity: 8
Residents reviewed for advanced directives: 10
Residents reviewed for storage of drugs and biologicals: 8
Residents reviewed for refrigerators in rooms: 8
Residents affected by dignity deficiency: 1
Residents affected by advance directive deficiency: 1
Residents affected by medication storage deficiency: 2
Residents affected by refrigerator food safety deficiency: 1
Temperature reading: 36
Temperature reading: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aide G | Aide | Named in dignity deficiency for standing over Resident #30 while feeding |
| LVN H | Licensed Vocational Nurse | Named in advance directive deficiency for administering CPR to Resident #71 contrary to DNR |
| LVN F | Licensed Vocational Nurse | Interviewed regarding Resident #323's self-medication assessment and policy |
| DON | Director of Nursing | Interviewed regarding expectations for dignity, medication security, and self-medication policies |
| Administrator | Administrator | Interviewed regarding advance directive process and medication security expectations |
| Caregiver B | Private Caregiver | Interviewed regarding Resident #5's refrigerator |
| Caregiver C | Private Caregiver | Interviewed regarding Resident #5's refrigerator monitoring and cleaning |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 10, 2024
Visit Reason
Annual survey inspection of Presbyterian Village North Special Care Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Presbyterian Village North Special Care Center following a survey completed on 11/21/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
The inspection was conducted as a standard annual survey of Presbyterian Village North Special Care Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection, indicating full compliance with applicable health standards.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with health and safety regulations at Presbyterian Village North Special Care Center.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 2
Date: Mar 29, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service safety standards and infection prevention and control protocols.
Findings
The facility failed to properly store and label food items in the kitchen's dry storage room, including expired foods and unlabeled packages, posing a risk for food-borne illness. Additionally, a staff member failed to perform proper hand hygiene during incontinent care for a resident, increasing the risk of infection transmission.
Deficiencies (2)
Failed to ensure food was properly stored and expired foods were discarded in the dry storage room.
Failed to maintain an infection control program; CNA failed to perform hand hygiene while providing incontinent care to Resident #48.
Report Facts
Residents affected: Some
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Failed to perform hand hygiene during incontinent care for Resident #48 |
| DON | Director of Nursing | Provided interview regarding hand hygiene policies and in-service training |
| Culinary Services Director | Provided information on food storage charts and food service provider communications | |
| Chef | Interviewed regarding food labeling and equipment cleaning schedule | |
| Clinical Nutritional Coordinator | Provided information on cleaning schedules and expiration date forms | |
| Administrator | Interviewed regarding awareness of food labeling and storage issues |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
The inspection was conducted as an annual survey of Presbyterian Village North Special Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating full compliance with applicable standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 4
Date: Feb 2, 2022
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident assessments, care planning, and food safety in the facility.
Findings
The facility failed to complete timely comprehensive assessments for newly admitted residents, develop and implement complete and accurate care plans with measurable objectives and timeframes, and maintain sanitary food preparation and serving practices including proper food temperatures and hand hygiene.
Deficiencies (4)
Failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days after admission for Resident #1.
Failed to develop and implement person-centered, comprehensive care plans with measurable objectives and timeframes for Residents #58, #60, and #46.
Failed to revise Resident #58's care plan to reflect change in code status within 7 days of comprehensive assessment.
Failed to ensure food was prepared, distributed, and served under sanitary conditions, including maintaining proper food temperatures and appropriate hand hygiene by dietary staff.
Report Facts
Residents reviewed for care plans: 18
Residents affected by care plan deficiencies: 3
Residents affected by assessment deficiency: 1
Residents affected by food safety deficiency: Many
Minimum internal temperature for poultry: 165
Date of survey completion: Feb 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator B | MDS Coordinator | Responsible for completing Resident #1's MDS assessment; acknowledged delay due to staffing issues |
| Interim DON | Interim Director of Nursing | Discussed staffing issues impacting MDS assessments and care plans; responsible for follow-up |
| MDS Coordinator A | MDS Coordinator | Responsible for comprehensive care plans; acknowledged oversights in care planning for Residents #58 and #46 |
| LVN C | Licensed Vocational Nurse | Provided information about Resident #46's antibiotic therapy and wound care |
| Clinical Coordinator | Clinical Coordinator | Responsible for updating wound care in Resident #46's care plan |
| Dietary Manager | Dietary Manager | Observed handling food improperly and not maintaining proper food temperatures during meal service |
| Administrator | Facility Administrator | Confirmed expectations for food safety and infection control practices in dietary services |
Viewing
Loading inspection reports...
