Deficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Texas average
Texas average: 3.5 deficiencies/year
Deficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to evaluate compliance with nutritional and food service standards in the nursing home, including menu adherence, food palatability, food preparation, and food safety practices.
Findings
The facility failed to ensure menus were followed, food was palatable and served at appropriate temperatures, food was prepared in the correct texture for individual needs, and food was stored, labeled, and disposed of according to professional standards. These deficiencies affected several residents and posed risks including poor intake, dissatisfaction, choking hazards, and potential foodborne illness.
Deficiencies (4)
Failed to ensure the menu was followed for 1 of 18 residents; Resident #10 did not receive items listed on his lunch meal ticket on 06/05/2025.
Failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for 2 of 18 residents (Residents #10 and #26) on 06/16/2025.
Failed to ensure food was prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #15); pureed vegetables were not the proper texture.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; food items were not labeled properly and spoiled food was not disposed of properly.
Report Facts
Residents reviewed for food and nutrition services: 18
Residents reviewed for meals: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Food items not labeled: 5
Food items not labeled: 3
Food items not labeled: 3
Individual glasses of liquid not labeled: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DS B | Weekend Supervisor | Responsible for unloading truck and labeling food items; stated food items should be labeled and disposed of properly. |
| DM | Dietary Manager | Responsible for monitoring kitchen staff, ensuring meal tickets are followed, food is prepared and served properly, and food labeling and disposal compliance. |
| RRN | Registered Nurse | Stated expectations for staff to follow policy regarding meal service, food preparation, and food safety; responsible for monitoring dietary staff compliance. |
| [NAME] C | Cook | Observed preparing pureed food incorrectly; stated he was nervous and forgot to look at recipes. |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to assess compliance with nutritional and food service standards in the nursing home, including menu adherence, food palatability, food preparation, and food safety practices.
Findings
The facility failed to ensure menus were followed, food was palatable and served at appropriate temperatures, food was prepared in forms meeting individual resident needs, and food was stored, labeled, and disposed of according to professional standards. These deficiencies affected several residents and posed risks including poor intake, dissatisfaction, choking hazards, and potential foodborne illness.
Deficiencies (4)
Failed to ensure the menu was followed for 1 of 18 residents; Resident #10 did not receive items listed on his lunch meal ticket on 06/05/2025.
Failed to ensure food was palatable, attractive, and served at a safe and appetizing temperature for 2 of 18 residents (Residents #10 and #26) on 06/16/2025.
Failed to ensure food was prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #15); pureed vegetables were not the proper texture.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; food items were not labeled properly and spoiled food was not disposed of properly.
Report Facts
Residents reviewed for food and nutrition services: 18
Residents reviewed for meals: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Food items not labeled: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DS B | Weekend Supervisor | Responsible for unloading truck weekly and labeling food items; stated food items should be labeled and disposed of properly. |
| DM | Dietary Manager | Responsible for monitoring kitchen staff, ensuring meal tickets are followed, food is prepared and served properly, and food labeling and disposal compliance. |
| RRN | Registered Nurse | Stated expectations for staff to follow policy regarding meal service, food preparation, and food safety; responsible for monitoring dietary and administrative staff. |
| [NAME] C | Cook | Observed pureeing vegetables without thickener; stated he was nervous and forgot to look at recipes. |
| CNA D | Certified Nursing Assistant | Assisted Resident #15 with eating her meal. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 17, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with Medicare and Medicaid regulations, including review of resident care, infection control, food service, and documentation accuracy.
Findings
The facility was found deficient in multiple areas including failure to provide advance notice of Medicare coverage changes, inaccurate resident assessments, inadequate respiratory care, poor food service practices including temperature and hygiene issues, and failure to maintain infection prevention and control protocols.
Deficiencies (6)
Failed to provide advance notice of change in services and charges not covered under Medicare for Resident #45.
Failed to ensure accurate assessments reflecting residents' status for Residents #5, #15, and #50.
Failed to provide safe and appropriate respiratory care for Residents #19 and #183, including weekly tubing changes and proper storage of equipment.
Failed to ensure food and drink were palatable, attractive, and at safe and appetizing temperatures.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including sealing opened food, maintaining temperature logs, and proper hygiene.
Failed to implement infection prevention and control program, including failure of CNA to perform hand hygiene and avoid contact with face while feeding Resident #60.
Report Facts
Medicare Part A service days: 20
Weight gain percentage: 9.51
Weight loss percentage: 8.9
Weight loss percentage: 11.11
Oxygen liters per minute: 3
Oxygen liters per minute: 2
Food temperature: 110
Food temperature: 154
Food temperature: 158
Food temperature: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator C | Interviewed regarding use of Medicare notification forms and Resident #45's discharge. | |
| MDS Coordinator B | Interviewed regarding assessment accuracy and facility policies. | |
| CNA A | Certified Nursing Assistant | Observed and interviewed regarding failure to perform hand hygiene while feeding Resident #60. |
| Dietary Manager | Interviewed regarding kitchen sanitation, cleaning schedules, and food service issues. | |
| Regional Compliance Nurse | Interviewed regarding food service and infection control issues. | |
| Administrator | Interviewed regarding ongoing food service issues and resident concerns. | |
| DON | Director of Nursing | Interviewed regarding infection control expectations and dietary issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
The inspection was conducted based on concerns regarding infection control practices at the facility, specifically related to hand hygiene and glove use during incontinence care for Resident #1.
Complaint Details
The visit was complaint-related due to observed failures in infection control practices by CNAs, including failure to perform hand hygiene and change gloves appropriately. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to maintain an effective infection prevention and control program, as CNAs did not perform proper hand hygiene or change gloves appropriately while providing care, placing residents at risk for infection transmission.
Deficiencies (1)
Failed to ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of two residents reviewed for infection control practices.
Report Facts
Residents reviewed for infection control practices: 2
Residents affected: 1
Length of employment: 1
Length of employment: 7
Date of Resident #1 face sheet: Jan 30, 2024
Date of Resident #1 MDS assessment: Jan 17, 2024
Date of Resident #1 care plan: Dec 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Failed to perform hand hygiene and change gloves appropriately during incontinence care; interviewed about infection control training and practices |
| CNA D | Certified Nursing Assistant | Failed to perform hand hygiene and change gloves appropriately during incontinence care; interviewed about infection control training and practices |
| DON | Director of Nursing | Acknowledged awareness of infection control concerns and expectations for aides to follow standard precautions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
The inspection was conducted based on concerns regarding infection control practices at the facility, specifically related to hand hygiene and glove use during incontinence care for Resident #1.
Complaint Details
The visit was complaint-related due to observed failures in infection control practices by CNAs during care of Resident #1. The complaint was substantiated based on observations, interviews, and record review.
Findings
The facility failed to maintain an effective infection prevention and control program, as CNAs did not perform proper hand hygiene or change gloves appropriately while providing care, placing residents at risk for infection transmission.
Deficiencies (1)
Failure to ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident.
Report Facts
Residents reviewed for infection control practices: 2
Resident age: 90
Length of employment: 1
Length of employment: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Failed to perform hand hygiene and change gloves appropriately during incontinence care; interviewed about infection control training and practices. |
| CNA D | Certified Nursing Assistant | Failed to perform hand hygiene and change gloves appropriately during incontinence care; interviewed about infection control training and practices. |
| DON | Director of Nursing | Acknowledged concerns about infection control and stated aides were expected to follow standard precautions. |
Inspection Report
Routine
Deficiencies: 4
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication security, and infection control practices at University Park Nursing and Rehabilitation.
Findings
The facility failed to complete a comprehensive assessment within 14 days after a significant change in condition for one resident, inaccurately assessed weight gain in quarterly MDS records, failed to secure medications on a medication cart, and did not maintain proper infection prevention and control practices including PPE use in COVID-19 positive resident rooms.
Deficiencies (4)
Failed to complete a comprehensive assessment within 14 days after a significant change in condition for Resident #1.
Failed to accurately assess weight gain in Resident #1's Quarterly MDS assessment records.
Medications were not secured on one of two medication carts reviewed, leaving medications unattended and accessible.
Failed to maintain infection prevention and control program; staff entered COVID-19 positive resident rooms without required PPE including eye protection, gowns, and N95 masks.
Report Facts
Resident weight: 130
Resident weight: 142
Resident weight: 151
Date of inspection: Dec 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Left prescription IV medication unattended on medication cart; admitted failure to lock medication. | |
| CNA A | Entered COVID-19 positive resident room without eye protection; admitted forgetting PPE. | |
| CNA B | Entered COVID-19 positive resident room without eye protection, gown, or N95 mask; admitted failure to follow PPE protocols. | |
| MDS Coordinator | Responsible for completing MDS assessments; admitted failure to complete Significant Change MDS assessment. | |
| DON | Director of Nursing | Stated responsibility for MDS assessment accuracy and medication security expectations. |
| Administrator | Stated infection control postings should be followed exactly and staff have been trained. |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, PASRR evaluations, care planning, respiratory care, nurse staffing information posting, food safety, and equipment maintenance at University Park Nursing and Rehabilitation.
Findings
The facility failed to complete timely comprehensive assessments after significant changes in condition, failed to complete and update PASRR evaluations, failed to develop and implement complete care plans, failed to ensure safe respiratory care with proper physician orders, failed to post daily nurse staffing information, and failed to maintain food safety and equipment standards in the kitchen, including improper dishwashing procedures, food storage, and freezer temperature maintenance.
Deficiencies (8)
Failed to complete a comprehensive assessment within 14 days after a significant change in condition for Resident #39.
Failed to ensure assessments with the PASRR program were conducted for Resident #56.
Failed to notify the state mental health authority promptly for resident review after a significant change in mental condition for Residents #21 and #55.
Failed to develop and implement care plans for necessary treatments and conditions for Resident #21.
Failed to provide safe and appropriate respiratory care for Resident #219 due to lack of physician's orders for oxygen administration.
Failed to post daily nurse staffing information with current date, resident census, and staff hours on 4/02/23.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper dishwashing procedures, food storage, soiled floors, and unclean equipment.
Failed to maintain reach-in freezer unit #2 at zero degrees F or below; food stored was not frozen solid.
Report Facts
Deficiencies cited: 8
Dish machine sanitizer level: 200
Freezer temperature: 25
Freezer temperature: 12
Freezer temperature: -4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Responsible for completing assessments and PASRR screenings; acknowledged failures in assessment and PASRR updates | |
| DON | Director of Nursing | Acknowledged responsibility for care plan accuracy and nurse staffing posting |
| Dietary Aide C | Dietary Aide | Handled dishwashing without gloves and failed to maintain sanitizer levels |
| DSM | Dietary Services Manager | Provided information on kitchen conditions and food safety issues |
| Maintenance Director | Maintenance Director | Addressed freezer maintenance and repair |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2023
Visit Reason
The inspection was conducted due to concerns about infection control practices at the facility, specifically related to the failure to maintain an infection prevention and control program.
Complaint Details
The visit was complaint-related due to concerns about infection control practices. The deficiency was substantiated with findings including improper hand hygiene and glove use by a CNA during resident care.
Findings
The facility failed to maintain an infection prevention and control program, as evidenced by a CNA not performing proper hand hygiene and glove changes while providing incontinence care to a resident, potentially placing residents at risk for infection spread.
Deficiencies (1)
Failure to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in infection control deficiency for failing to perform proper hand hygiene and glove changes. | |
| DON | Director of Nursing | Interviewed regarding infection control concerns and facility protocols. |
| ADON B | Assistant Director of Nursing | Responsible for infection control and monitoring staff compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2023
Visit Reason
The inspection was conducted due to concerns about infection prevention and control practices at the facility, specifically related to hand hygiene and glove use during incontinence care for Resident #1.
Complaint Details
The visit was complaint-related, focusing on infection control practices. The deficiency was substantiated based on observation, interview, and record review.
Findings
The facility failed to maintain an effective infection prevention and control program, as evidenced by CNA A's failure to perform proper hand hygiene and glove changes while providing care to Resident #1, potentially placing residents at risk for infection transmission.
Deficiencies (1)
Failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in infection control deficiency for failure to perform proper hand hygiene and glove changes. | |
| DON | Director of Nursing | Interviewed regarding infection control concerns and facility protocols. |
| ADON B | Assistant Director of Nursing | Responsible for infection control and monitoring staff compliance. |
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