Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to abuse prevention, activities of daily living care, nursing coverage, medication administration, food service safety, and other facility operations.
Findings
The facility failed to implement timely background checks for employees, provide adequate assistance with activities of daily living for a resident, maintain required RN coverage on weekends, ensure medication error rates were below 5%, and maintain proper dishwasher thermometer function. These deficiencies posed risks of abuse, neglect, medication errors, missed nursing care, and foodborne illness.
Deficiencies (5)
Failed to develop and implement policies and procedures to prevent abuse, neglect, and theft, including failure to conduct employee background checks at least annually for 3 staff members.
Failed to provide timely incontinence care to Resident #34, risking skin breakdown, pain, and infection.
Failed to have a registered nurse on duty for at least 8 consecutive hours a day, 7 days a week during July and August 2024.
Medication error rate of 11% with errors including incorrect dose of Nicotine gum, incorrect dose of Acetaminophen, and improper IV infusion rate of Cefepime.
Failed to ensure the thermometer on the low temperature dishwashing machine was in working condition, risking foodborne illness.
Report Facts
Medication error rate: 11
Medication errors: 3
RN coverage months: 2
Dishwasher temperature log missing data days: 18
Dishwasher PPM: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Named in failure to conduct timely background checks | |
| LVN D | Named in failure to conduct timely background checks | |
| LVN E | Named in failure to conduct timely background checks | |
| MA A | Medication Aide | Named in medication errors for incorrect dosing |
| LVN B | Licensed Vocational Nurse | Named in medication error and interview regarding medication administration |
| Human Resources Director | Interviewed about background check policies and failures | |
| Administrator | Interviewed about RN coverage and background check failures | |
| DON | Director of Nursing | Interviewed about nursing coverage, medication errors, and care expectations |
| Dishwasher A | Interviewed about dishwasher thermometer malfunction | |
| Dining Supervisor | Interviewed about dishwasher maintenance | |
| Chef | Interviewed about dishwasher temperature requirements |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 27, 2023
Visit Reason
The inspection was conducted due to complaints regarding unresolved resident grievances and failure to address concerns raised during resident council meetings from April to July 2023.
Complaint Details
The complaint investigation was triggered by resident grievances about unresolved issues including call light response times, meal errors, laundry damage, loud televisions, and other concerns. The facility failed to log grievances or follow up on them. Interviews with residents, staff, and administration confirmed ongoing unresolved grievances and lack of proper grievance tracking and resolution.
Findings
The facility failed to ensure grievances were resolved for 3 residents, did not document or follow-up on grievances expressed during resident council meetings, and failed to develop and implement person-centered care plans for residents, including failure to address repeated medication refusal for one resident. Multiple resident concerns about care, environment, and services were documented but not properly addressed or resolved.
Deficiencies (2)
Failed to ensure grievances were resolved for 3 residents and did not document or follow-up on grievances expressed during resident council meetings from April to July 2023.
Failed to develop and implement person-centered care plans for Resident #22, specifically not including the resident's repeated refusal of Dronabinol medication.
Report Facts
Medication refusal dates: 23
Resident council meeting dates with concerns: 4
Length of administrator role: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Documented Resident #22's refusal of Dronabinol medication on multiple dates. | |
| LVN B | Documented Resident #22's refusal of Dronabinol medication and explained medication purpose to resident. | |
| Administrator | Administrator | Interviewed regarding grievance follow-up, resident council meetings, and care plan responsibilities. |
| DON | Director of Nursing | Interviewed about grievance resolution, staff in-service, and care plan accuracy. |
| MDS LVN | Interviewed about care plan development and review processes. | |
| Facility pharmacist | Interviewed regarding Resident #22's Dronabinol medication order and refusal. | |
| Resident council president | Mentioned as the sole attendee of resident council meetings and primary voice of grievances. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 16, 2022
Visit Reason
The inspection was conducted based on complaints related to inadequate supervision and assistive devices to prevent accidents, unsanitary kitchen conditions, failure to obtain hospice documentation, and infection prevention and control deficiencies.
Complaint Details
The complaint investigation included issues with supervision and assistive devices for fall prevention, kitchen sanitation, hospice documentation, and infection control practices. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure adequate supervision and assistive devices for a resident at risk of falls, maintain sanitary food storage and preparation practices, obtain current hospice plans and physician certifications for hospice residents, and implement proper infection prevention and control practices including hand hygiene and equipment sanitation.
Deficiencies (4)
Failed to ensure Resident #16 had bolsters and fall mats as ordered to prevent falls.
Failed to maintain sanitary kitchen conditions including improper storage of frozen foods and unsanitary freezers and refrigerators.
Failed to obtain current hospice plan of care and physician certification for Resident #1 under hospice care.
Failed to maintain infection prevention and control program; staff failed hand hygiene during eye drop administration and contaminated nasal cannula tubing was reused.
Report Facts
Residents reviewed for supervision and assistive devices: 16
Kitchen sanitation reviewed: 1
Residents reviewed for hospice services: 3
Staff observed for infection control: 2
Residents observed for infection control: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Stated expectation that bolsters were to be on Resident #16's bed as ordered. |
| ADON | Assistant Director of Nursing | Discussed missing fall mats and bolsters for Resident #16 and initiated staff training. |
| DON | Director of Nursing | Stated expectation that care plans and physician orders be followed and was the designated person to coordinate hospice services. |
| Dining Room Manager | Discussed kitchen sanitation issues and cleaning schedules. | |
| Nurse Manager | Unable to locate hospice binder for Resident #1. | |
| MA C | Medication Aide | Failed to perform hand hygiene during eye drop administration to Resident #21. |
| MA D | Medication Aide | Failed to perform hand hygiene during eye drop administration to Resident #19. |
| LVN E | Licensed Vocational Nurse | Failed to change contaminated nasal cannula tubing before placing it back on Resident #1. |
| ADON | Assistant Director of Nursing | Stated hand washing was expected for eye drop administration and staff was to perform hand hygiene and glove changes. |
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