Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
251% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, pharmaceutical services, infection prevention and control, and overall facility operations.
Findings
The facility was found deficient in ensuring residents' dignity by failing to cover urinary catheter bags with privacy bags for two residents, failing to provide wound care treatment as ordered for one resident due to incorrect order placement, and failing to maintain infection prevention and control by allowing a catheter bag to rest on the floor, risking infection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure urinary catheter bags were covered with privacy bags for residents, risking loss of dignity. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide wound care treatment according to physician's orders due to incorrect order placement in the MAR. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection prevention and control by allowing a urinary catheter bag to rest on the floor, risking infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for resident rights: 3
Residents reviewed for medication administration: 2
Residents reviewed for infection control: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| J | Admitting Nurse | Provided wound care treatment for Resident #1. |
| DON | Director of Nursing | Interviewed regarding wound care documentation and catheter bag privacy and infection control. |
| RN | Registered Nurse | Provided information about wound care documentation and order review. |
| Medical Record Director | Interviewed regarding wound care documentation for Resident #1. | |
| Administrator | Interviewed regarding wound care documentation and order review responsibilities. | |
| Physician | Interviewed regarding wound care risks and expectations for order review. | |
| CNA A | Certified Nursing Assistant | Addressed catheter bag on floor and discussed infection control training. |
| CNA B | Certified Nursing Assistant | Interviewed about catheter bag privacy and rounding responsibilities. |
| CNA D | Certified Nursing Assistant | Interviewed about catheter bag privacy and infection risk. |
| CNA E | Certified Nursing Assistant | Interviewed about catheter bag privacy and infection control responsibilities. |
| CNA F | Certified Nursing Assistant | Interviewed about catheter bag privacy bag availability and use. |
| LVN C | Licensed Vocational Nurse | Interviewed about catheter bag infection risk and rounding. |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 6
Dec 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including staffing adequacy, pharmaceutical services, medication management, call light system functionality, and medical record accuracy.
Findings
The facility was found deficient in multiple areas including insufficient nursing staff leading to delayed care, failure to post daily nurse staffing data, failure to administer medications as ordered due to unavailability and lack of timely physician notification, improper medication storage and handling, malfunctioning resident call light systems, and incomplete medical record documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Potential for minimal harm: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Insufficient nursing staff resulting in missed showers, delayed response to call lights, and delayed incontinent care for dependent residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post nurse staffing information daily and maintain it accessible to residents and visitors since 11/20/25. | Level of Harm - Potential for minimal harm |
| Failure to provide pharmaceutical services meeting residents' needs, including failure to administer multiple medications as ordered and failure to notify physicians promptly when medications were unavailable. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals were stored and disposed of in accordance with laws; medications were left unattended at the nurse's station. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to safeguard resident-identifiable information and maintain accurate medical records, including failure to document physician notifications and telephone orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to have a working call system in each resident's bathroom and bathing area; call lights did not ring at nurse's stations or residents' rooms for several days. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident census: 51
Number of residents reviewed for staffing: 5
Number of CNAs scheduled: 3
Number of CNAs working: 2
Medication non-administration events: 30
Packing slip medications: 4
Call light system QA checks: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in failure to document physician notification and telephone orders for Resident #1 |
| RN D | Assistant Chief Nursing Officer | Interviewed regarding nurse staffing data posting and medication administration |
| RN Assistant Chief Nursing Officer | Interviewed regarding medication administration, nurse staffing, and medication storage | |
| LVN B | Licensed Vocational Nurse | Demonstrated call light malfunction to surveyor |
| LVN C | Licensed Vocational Nurse | Interviewed about staffing and care delays |
| CNA E | Certified Nursing Assistant | Observed providing incontinent care and interviewed about staffing |
| CNA H | Certified Nursing Assistant | Interviewed about staffing and call light system |
| Maintenance Director | Interviewed about medication deliveries and call light system malfunction | |
| Executive Director | Interviewed about staffing, call light system, and facility operations |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 3, 2025
Visit Reason
The inspection was conducted to assess compliance with care planning requirements, specifically to determine if the facility developed and implemented comprehensive person-centered care plans that include measurable objectives and time frames to meet residents' medical and nursing needs.
Findings
The facility failed to develop and implement comprehensive person-centered care plans for two residents using wound vacs, which could put residents at risk for not receiving appropriate care and services. Interviews and record reviews confirmed that wound vac treatments were not included in the care plans, despite being part of the residents' treatment needs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, including wound vac treatment, with measurable timetables and actions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plans: 4
Residents affected: 2
BIMS score: 15
Wound vac pressure: 125
Inspection Report
Routine
Deficiencies: 8
Mar 26, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards for food service safety and the maintenance of accurate and complete medical records in the facility.
Findings
The facility failed to maintain food service safety standards in the kitchen, including improper food storage, unclean equipment, and unsanitary conditions that could risk food contamination. Additionally, the facility failed to document a resident's fall incident per policy, risking incomplete resident records.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Access to trash can next to handwashing sink was not hands free due to damaged lid. | Level of Harm - Minimal harm or potential for actual harm |
| Food items in the walk-in refrigerator were not sealed or labeled appropriately. | Level of Harm - Minimal harm or potential for actual harm |
| Food items in the walk-in freezer were not dated or stored appropriately. | Level of Harm - Minimal harm or potential for actual harm |
| Dishwashing and sanitization machine was dirty with dried caked on substance. | Level of Harm - Minimal harm or potential for actual harm |
| Kitchen ice machine was dirty with dried caked on substance around the dispenser door. | Level of Harm - Minimal harm or potential for actual harm |
| Multiple vents over cooking prep areas were dirty with dust and debris. | Level of Harm - Minimal harm or potential for actual harm |
| Wall and ceiling in kitchen prep area had dried yellow splatter not cleaned promptly. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document Resident #1's fall incident per policy in an incident report. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Trash can size: 13
BIMS score: 11
Date of fall incident: Feb 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding kitchen sanitation and food safety deficiencies |
| LVN E | Licensed Vocational Nurse | Assessed Resident #1 after fall and documented in progress notes |
| LVN F | Licensed Vocational Nurse | Covered LVN E's hall during fall incident and notified LVN E |
| CNA H | Certified Nursing Assistant | Found Resident #1 on restroom floor after fall and notified LVN F |
| Administrator | Facility Administrator | Interviewed about kitchen sanitation responsibilities |
| DON | Director of Nursing | Interviewed about kitchen sanitation and incident report policies |
Inspection Report
Routine
Deficiencies: 1
Jul 19, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically to assess compliance with infection control practices related to disposal of soiled briefs and wipes.
Findings
The facility failed to properly dispose of a resident's dirty brief and wipes smeared with feces that were left on the floor wrapped in a linen, posing a risk for cross contamination and infection. Interviews and record reviews confirmed lapses in adherence to infection prevention protocols by staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to dispose of Resident #3's dirty brief and wipes smeared with feces left on the room floor wrapped in a linen. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA | CNA A was responsible for Resident #3 and admitted to leaving dirty brief and wipes on the floor wrapped in a linen. | |
| Director of Nursing (DON) | The DON stated CNAs and charge nurses were responsible for ensuring proper disposal of dirty briefs and wipes and described training provided. |
Inspection Report
Routine
Deficiencies: 3
Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards related to IV fluid administration, food service safety, infection prevention and control, and enhanced barrier precautions in the facility.
Findings
The facility was found deficient in several areas including failure to properly change soiled midline dressings, improper food storage and labeling, inadequate infection control practices including improper hand hygiene by staff, and failure to implement enhanced barrier precautions for residents with indwelling devices or wounds.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents received parenteral fluids administered consistent with professional standards and physician orders, specifically failure to change Resident #237's soiled midline dressing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, distribute, and serve food in accordance with professional standards, including improper labeling and storage of raw meat and frozen vegetables. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an infection prevention and control program, including improper hand hygiene and glove changes by CNA D during incontinence care for Resident #137, and failure to identify residents for enhanced barrier control. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents with open wounds: 7
Residents with g-tubes: 2
Residents with catheters: 3
Residents with dialysis shunts: 6
Residents with intravenous medications: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for improper hand hygiene and glove use during incontinence care for Resident #137 |
| DON | Director of Nursing | Interviewed regarding infection control practices and enhanced barrier precautions implementation |
| ADON A | Assistant Director of Nursing | Interviewed regarding midline dressing changes and facility practices |
| ADON B | Assistant Director of Nursing | Interviewed regarding midline dressing changes and facility practices |
| Food Service Director | Interviewed regarding food storage and labeling deficiencies | |
| Registered Dietician | Interviewed regarding food storage and labeling deficiencies | |
| Administrator | Interviewed regarding enhanced barrier precautions implementation | |
| LVN C | Licensed Vocational Nurse | Interviewed regarding Resident #87's dialysis and room signage |
Inspection Report
Routine
Deficiencies: 8
Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, medication administration, infection control, laboratory services, medication storage, food safety, and IV fluid administration.
Findings
The facility failed to ensure accurate resident assessments, comprehensive care plans, proper medication use, safe IV fluid administration, secure medication storage, timely laboratory services, proper food storage, and effective infection prevention and control practices. Specific deficiencies included inaccurate MDS assessments, incomplete care plans, unnecessary psychotropic medication use, failure to change soiled IV dressings, unlocked medication carts, missed lab orders, unlabeled food items, and inadequate infection control measures including improper glove use and lack of enhanced barrier precautions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to conduct assessments that accurately reflected residents' status for 4 of 12 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans for residents #10, #15, and #28. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe, appropriate administration of IV fluids; midline dressing was not changed after becoming soiled for Resident #237. | Level of Harm - Minimal harm or potential for actual harm |
| Medication carts were left unlocked and unattended, risking drug diversion or accidental ingestion. | Level of Harm - Minimal harm or potential for actual harm |
| Residents received psychotropic medications without appropriate diagnoses or care plans for Residents #10, #21, and #137. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely laboratory services; physician orders for labs were not followed for Resident #136. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute, and serve food in accordance with professional standards; unlabeled and undated food items found in kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program; improper glove use during incontinence care and lack of enhanced barrier precautions for residents with indwelling devices. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for resident assessments: 12
Residents reviewed for care plans: 6
Medication carts observed unlocked: 3
Residents affected by infection control failures: 4
Residents with indwelling devices: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Named in infection control finding for improper glove use during incontinence care for Resident #137. | |
| LVN B | Charge nurse on duty when physician orders for Resident #136's lab tests were not received. | |
| DON | Director of Nursing | Provided multiple interviews regarding assessment, care planning, infection control, medication administration, and facility policies. |
| ADON A | Assistant Director of Nursing | Interviewed regarding midline dressing changes and medication cart security. |
| ADON B | Assistant Director of Nursing | Interviewed regarding midline dressing changes and medication cart security. |
| Administrator | Interviewed regarding medication cart security and enhanced barrier precautions implementation. | |
| Food Service Director | Interviewed regarding food storage and labeling deficiencies. | |
| Registered Dietician | Interviewed regarding food storage and labeling deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents receive treatment and care according to professional standards and care plans, specifically focusing on repositioning of residents.
Findings
The facility failed to ensure Resident #3 was repositioned every 2 hours as required, placing the resident and potentially others at risk for medical complications such as pressure ulcers. Observations and interviews confirmed Resident #3 was not repositioned during the morning, and the responsible CNA acknowledged the failure. The Director of Nursing and Administrator confirmed staff responsibilities for repositioning and monitoring.
Complaint Details
The visit was complaint-related focusing on repositioning of Resident #3. The complaint was substantiated as the facility failed to reposition the resident every 2 hours, confirmed by observations and staff interviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #3 was repositioned every 2 hours according to care plan and professional standards. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for repositioning: 6
Residents affected: 1
Time of last repositioning: 10.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Responsible for Resident #3 and acknowledged failure to reposition resident in the morning |
| RN B | Registered Nurse | Provided information about repositioning responsibilities and risks |
| DON | Director of Nursing | Assisted with repositioning Resident #3, assessed skin condition, and described staff responsibilities |
| Administrator | Facility Administrator | Confirmed staff responsibilities and monitoring for repositioning |
Inspection Report
Routine
Deficiencies: 8
Apr 14, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident rights, medication administration, respiratory care, dietary services, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' advance directives were properly documented, incomplete baseline care plans, improper medication administration via g-tube, failure to change midline dressings as ordered, inadequate respiratory care including oxygen tubing changes and signage, improper labeling of feeding bags and medications, failure to serve food in prescribed consistencies, and food safety violations including improper labeling and glove use in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure Resident #23's advance directive (DNR) was properly documented and consistently indicated in the physical chart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a baseline care plan including anticoagulant instructions for Resident #96. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to change Resident #39's midline dressing according to physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate respiratory care including changing oxygen tubing weekly, posting oxygen signs, and storing respiratory masks properly for Residents #8, #5, and #96. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer medications via g-tube according to physician orders for Resident #247, including mixing medications together and incorrect fluid amounts. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to label feeding bags and flush bags properly for Resident #247. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to serve Resident #246 food and liquids in the prescribed puree texture and thin liquid consistency, instead serving nectar consistency liquids. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, and serve food in accordance with professional standards including unlabeled hotdog buns, expired and unlabeled chocolate syrup, and improper glove use during food preparation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for advance directives: 6
Residents reviewed for baseline care plans: 6
Residents reviewed for quality of care: 16
Residents observed for oxygen management: 5
Residents reviewed for medication administration: 3
Residents reviewed for dietary services: 2
Hotdog buns: 3
Medication administration times: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Named in medication administration deficiency for Resident #247. | |
| RN Licely [NAME] | Registered Nurse | Interviewed regarding Resident #23's advance directives and code status. |
| Patty [NAME] | Interviewed regarding advance directives and admission procedures. | |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including advance directives, medication administration, respiratory care, and dietary services. |
| LVN A | Licensed Vocational Nurse | Interviewed regarding oxygen management and signage. |
| LVN B | Licensed Vocational Nurse | Interviewed regarding oxygen management and feeding bag labeling. |
| RN H | Registered Nurse | Interviewed regarding infection control and nebulizer mask storage. |
| Culinary Director [NAME] | Culinary Director | Interviewed regarding food safety, labeling, and glove use. |
| Cook G | Cook | Observed and interviewed regarding glove use and food preparation. |
| Speech Therapist | Interviewed regarding swallowing evaluations and diet consistency for Resident #246. | |
| LVN E | Licensed Vocational Nurse | Interviewed regarding documentation of swallowing issues for Resident #246. |
| Administrator | Interviewed regarding policies and procedures related to diet orders and medication administration. |
Inspection Report
Routine
Deficiencies: 10
Feb 16, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, dietary services, and facility safety.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete care plans, improper respiratory care, medication errors, failure to maintain controlled drug counts, inadequate food preparation and storage, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure assessments accurately reflected resident's status, specifically dental condition for Resident #34. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans that meet all resident needs, including oxygen therapy and dental care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care; oxygen tubing for Residents #23, #189, and #190 were not dated. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pharmaceutical services assuring accurate medication administration and reconciliation; multiple medication errors and failure to sign controlled drug count records. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was prepared in a form designed to meet individual needs; pureed food portions were insufficient and Resident #6 did not receive finely chopped foods as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure, store, prepare, distribute, and serve food in accordance with professional standards; food items in dry storage, freezer, refrigerators were opened, undated, unsealed, and food prep areas were unsanitary. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement infection prevention and control program; catheter bags and tubing were resting on the floor without protective covers, and visitor screening for Covid-19 was inconsistent. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure controlled drugs were properly accounted for; controlled medications were not removed upon resident discharge and controlled drug count sheets were not consistently signed at shift changes. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #13 was administered antipsychotic medication (Olanzapine) without a diagnosis of psychosis and without documented attempts at gradual dose reduction. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate exceeded 5%; four medication errors were identified involving insulin administration, multivitamin, calcium acetate, and sucralfate. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 12
Residents reviewed for accuracy of assessments: 12
Residents reviewed for care plans: 12
Residents reviewed for oxygen therapy: 12
Residents reviewed for pharmaceutical services: 12
Residents reviewed for food provision: 158
Residents reviewed for infection control: 15
Pureed diet servings prepared: 10
Pureed diet residents served: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Named in medication error findings including insulin and multivitamin administration |
| LVN B | Licensed Vocational Nurse | Named in medication error findings including calcium acetate and sucralfate administration |
| CNA F | Certified Nursing Assistant | Reported resident #34's tooth pain and refusal of dental care |
| LVN M | Licensed Vocational Nurse | Reported on oxygen tubing dating and nasal cannula care |
| LVN O | Licensed Vocational Nurse | Reported on oxygen tubing dating and nasal cannula care |
| DON | Director of Nursing | Provided multiple interviews regarding care plans, medication administration, infection control, and staff training |
| ADON | Assistant Director of Nursing | Provided interviews regarding care plans, medication administration, and infection control |
| Receptionist K | Receptionist | Provided interview regarding Covid-19 visitor screening procedures |
| Receptionist L | Receptionist | Provided interview regarding Covid-19 visitor screening procedures |
| Food Director | Food Service Director | Provided interviews and observations regarding dietary services and food preparation |
| Dietitian Consultant | Dietitian | Provided interviews regarding dietary services and food preparation |
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