Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements, specifically to verify the facility's adherence to staffing requirements including registered nurse coverage.
Findings
The facility failed to ensure registered nurse coverage for at least 8 consecutive hours a day, 7 days a week, on five specific weekend dates within the 90-day review period. This deficiency could place residents at risk of adverse events due to lack of proper RN coverage.
Deficiencies (1)
Failure to maintain registered nurse coverage for 8 hours a day, 7 days a week on specified weekend dates.
Report Facts
Days without 8-hour RN coverage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding RN coverage and staffing issues; stated she was not employed during the dates without coverage. |
| Staffing Coordinator | Interviewed about scheduling and RN coverage; responsible for staffing and notifying DON of vacancies. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements, focusing on care planning, communication barriers, and nursing coverage at The Vosswood Nursing Center.
Findings
The facility failed to develop and implement a comprehensive care plan addressing a resident's communication barrier within 7 days after the comprehensive assessment, and failed to ensure registered nurse coverage for at least 8 consecutive hours a day, 7 days a week on multiple weekends. These deficiencies placed residents at risk of not receiving appropriate care and timely nursing interventions.
Deficiencies (3)
Failed to inform and enable participation in treatment for Resident #16 due to incomplete care plan addressing communication barrier within 7 days after assessment.
Failed to develop and implement a complete care plan meeting all resident needs with measurable timetables and actions for Resident #16 within 7 days after assessment.
Failed to ensure registered nurse coverage for at least 8 consecutive hours a day, 7 days a week on 5 weekend days reviewed.
Report Facts
Days without 8-hour RN coverage: 5
Residents reviewed for care plans: 13
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Called Resident #16's family member to communicate and assess needs |
| DON | Director of Nursing | Interviewed regarding RN coverage and care plan management |
| CNA R | Certified Nursing Assistant | Reported Resident #16 communicated by gestures and spoke Vietnamese |
| Regional MDS Coordinator | Provided information on care plan requirements and facility staffing | |
| Staffing Coordinator | Discussed RN scheduling and coverage |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, medication administration, wound care, IV catheter care, and medical record documentation at The Vosswood Nursing Center.
Findings
The facility failed to provide physician orders for immediate care upon admission, failed to provide wound care and IV catheter site care for multiple residents, failed to administer medications as ordered including diuretics, antibiotics, and pain medications, and failed to maintain accurate and complete medical records including proper documentation of weights and use of individual login credentials.
Deficiencies (6)
Failed to provide physician orders for immediate care for a resident's surgical site from 01/18/23 to 01/20/23.
Failed to ensure services met professional standards for 4 residents including medication errors, lack of wound care, and IV catheter care.
Failed to provide appropriate treatment and care according to orders for a resident's surgical site from 01/18/23 to 01/20/23.
Failed to provide safe and appropriate administration of IV fluids and care for IV catheter sites for 2 residents from 12/30/22 to 01/23/23.
Failed to provide pharmaceutical services including acquiring, dispensing, and administering medications as ordered for 3 residents, resulting in missed doses of diuretics, pain medications, and IV antibiotics.
Failed to maintain complete and accurate medical records including documentation of weights and proper use of individual login credentials for documentation.
Report Facts
Missed medication doses: 7
Missed medication doses: 3
Missed medication doses: 1
Missed medication doses: 3
Medication error date: 1
Weight documentation dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Documented medication administration when clocked out and provided login credentials to agency nurse. |
| Agency Nurse #1 | Agency Nurse | Used LVN B's login credentials due to lack of EMR access and was unable to document tasks or administer medications from 04:00 AM to 06:00 AM on 01/19/23. |
| LVN D | Licensed Vocational Nurse | Administered wrong antibiotic to Resident #3 on 01/16/23; investigation incomplete. |
| DON | Director of Nursing | Responsible for auditing orders and ensuring proper documentation; unaware of some medication and documentation issues. |
| MD | Physician | Provided orders and commented on medication errors and resident conditions. |
| PA | Physician Assistant | Increased diuretic dose for Resident #1 and unaware of medication administration errors. |
| Pharmacist | Pharmacist | Reported first delivery dates for medications and pharmacy involvement. |
| Administrator | Facility Administrator | Responsible for ensuring agency nurses receive EMR access and proper credential use. |
Inspection Report
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for The Vosswood Nursing Center, summarizing the findings of a regulatory survey completed on 2023-02-06.
Findings
No health deficiencies were found during the survey.
Inspection Report
Deficiencies: 0
Date: May 12, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for The Vosswood Nursing Center, summarizing the results of a survey completed on 2022-05-12.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 15, 2021
Visit Reason
Annual inspection survey of The Vosswood Nursing Center conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are unknown.
Report
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