Capacity 68. 12-18
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
During the walkthrough, I observed an open water valve recess outside a cottage lacking a protective cover, creating a tripping hazard. The operation replaced this cover at the time of the inspection. |
Yes |
| 4 | — |
748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit
During the investigation inspection, it was discovered that New Lodge had a used fire extinguisher. According to staff and documentation the fire extinguisher was used eight days prior, and a request was submitted for a new one; however, the extinguisher for this Lodge has not been replaced yet. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the walkthrough, I observed holes in the drywall in the bedroom of one lodge and the downstairs bathroom of the second lodge. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, I observed a mini fridge in one of the cabins that exhibited a thermometer reading of 50 degrees Fahrenheit. The operation turned down the temperature in the unit during the inspection to correct the temperature. |
Yes |
| 3 | — |
748.1501(a)(1) - Dental care-Children in care must receive dental care initially according to the requirements in 748.1225
(2) out of (6) records reviewed were missing a dental examination. One record indicated that an appointment was rescheduled, however, there was not an appointment scheduled. |
— |
| 4 | — |
748.863(a)(5) - Pre-Service Training- Caregivers who administer medication must have psych medication training before administering psych meds.
During the inspection, we observed five of six employee files lacking the requisite administrating psychotropic medications training. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection, we observed three of four children's medication records to include medication logs with initials for ther person administering medications but not the full names of those individuals. |
— |
| 3 | — |
748.3365(a) - Bedding-must provide each child with an individual bed or bunk bed in child's room that elevates mattress off floor, or crib as appropriate
During the inspection, I observed four mattresses on the floor of loft areas in the cabins. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a safety plan established on 5/16/24 indicated a specific staff member would not administer restraints until the close of the ongoing investigation, but documentation indicates the staff member engaged in a restraint on 6/11/24. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the walkthrough, I observed excessive dust and cobwebs and cracked paint near the ceiling in one of the bedrooms. |
— |
| 5 | — |
745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone
During the inspection, I observed that one of the maintenance staff hired on 5/1/23 does not have an initial background upon hire with the facility. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
During the walkthrough, we observed uncovered food in the refrigerator of one of the cottages. |
— |
| 3 | — |
748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available
During the inspection, I observed one child's initial medical exam was completed 24 days past the 30 days from admission date. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
A child suffered an injury on 5/21/2025 while playing basketball, however, the child was not taken to seek medical attention until 5/29/2025. When the child was seen by medical, he was diagnosed with a closed fracture. |
— |
| 3 | — |
748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline
A child drank hand sanitizer and had to be taken to the Emergency Room. Staff failed to report this incident to the hotline. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
During the investigation inspection, there was a first aid kit stored, unlocked and accessible to children, in the bathroom of the East House. The first aid kid contained topical creams and cold compress both of which were labeled to keep out of reach of children. |
Yes |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the walkthrough, I observed broken tiles in the upstairs bathroom floor of a girl's house. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
During the DFPS investigation, it was discovered the operation failed to secure poisonous cleaning supplies, allowing children unsupervised access. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Two cabins were inspected and one bed was missing a mattress protector; and another bed was missing a pillowcase. |
— |
| 4 | — |
748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply
This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member utilized restraint as a means to gain compliance from a child that refused to leave a peer's room. |
— |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
In 4 of 4 records reviewed there was not a documented notice given for the child service planning meeting. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
Licensing was not notified within 24 hours of a child's diagnosed fracture. The diagnosis was provided on 5/29/2025 at approximately 530pm, however, the report to SWI did not occur until 5/30/2025 at approximately 630pm. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, I observed two refrigerators without requisite thermometers. |
— |
| 3 | — |
748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor
During the investigation inspection, there was potatoes stored on the pantry floor of New Lodge and Vickie's House. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
This deficiency was noted as part of a DFPS investigation. |
— |
| 4 | — |
748.2551(f) - EBI Implementation-If child doesn't understand what to do to be released, caregiver re-explains every 15 minutes until child understands or released
Two of the eight emergency behavior intervention records reviewed showed that caregivers failed to re-explain every 15 minutes what the child needed to do in order to be released from the intervention. |
— |
| 4 | — |
748.303(a)(2)(A) - Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
The operation failed to report a child in care was taken to the hospital for an allergic reaction to a known nut allergy, that warrant treatment by a medical professional. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the inspection, I observed mildew in the wooden shower and bathroom walls and celings of four cottages. A shower in one of the houses exhibited low water pressure. |
— |
| 4 | — |
748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.
In one of the six employee files read, the record did not reflect the employee receiving annual Normalcy training in the past two years. |
— |
| 3 | — |
748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers
During the walkthrough, we observed two bathrooms lacking handtowels in the restrooms. |
— |
| 2 | — |
748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children
During the investigation inspection, it was observed the four showers located in the East House only had lukewarm/room temperature water for the children to shower. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, I observed three refrigerator thermometers reading in excess of the permitted 40 degrees, and one deep freeze unit lacked a thermometer. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the monitoring inspection, one child's medication record was reviewed and observed to be missing the full name of the person who administered the medication. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the inspection, I observed a drainage issue in the sink of one cottage, a toilet holding human waste that did not cycle when tested in another cabin, and a cracked shower stall in a third cabin. None of these repairs had work orders filed on them at the time of the inspection. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member failed to secure a box of over-the-counter medication stored in the staff office, resulting in a resident accessing and ingesting the medication without supervision. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the investigation inspection, the thermometer located in the East House freezer indicated the freezer was at 16 degrees Fahrenheit, and not at the required 0 degree Fahrenheit or below. Additionally, the thermometer located in Vickie's House refrigerator indicated the refrigerator was at 45 degrees Fahrenheit, and not at the required 40 degree Fahrenheit or below. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the walkthrough, I observed missing trim with exposed nails inside a cabin bathroom and damaged drywall around the entry to a bedroom in another cabin with exposed corner protectors and around the window. |
— |
| 4 | — |
748.303(a)(11)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child
There were two unreported suicide attempts on 3/7 and 3/8/2021. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During the walkthrough, we observed the following physical site issues: A shower head in one of the resident bathrooms was broken and needed replacing, shower surround in one bathroom evidenced a peeling backing board above the shower surround, a small closet/storage area door in one of the cottages was broken with exposed nails, the cabinet in the laundry room of one cottage has been broken with a maintenance report on file since 7/27/24, a toilet in one cottage lacked a tank lid with a maintenance report filed 9/2/24. Items with maintenance reports on file are not being completed in a timely manner. |
— |
| 5 | — |
748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member restrained a child about the head or throat area during a restraint. |
— |
| 3 | — |
748.2855(a)(5) - EBI Documentation-Must include the date and time the intervention was administered
Six out of the eight emergency behavior interventions records reviewed showed no time of the incident. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the inspection, I observed a light switch in one cottage with a missing face plate, and a cabinet door in another cottage had a faulty hinge. |
— |
| 2 | — |
748.3393(d) - Toilets-Toilets must be equipped with toilet paper at all times
During the inspection, we observed a bathroom in one of the lodges lacking any toilet paper. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the investigation inspection, the dishwasher in New Lodge was observed to be dirty and a bathroom wall had mold/mildew. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Children in care were able to secure tools from restricted areas at the operation- which enabled them to dismantle the window in their cottage and engage in illegal activities. |
— |
| 4 | — |
748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
In one of six employee records reviewed, the caregiver employee did not receive 16 hours of EBI preservice training. Only two hours were documented for the employee in the file. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the inspection, I observed one of the beds in a boys cottage lacked a mattress cover. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
During the ANE investigation, it was discovered that five of six residents interviewed reported staff cursing and yelling at them. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the inspection I observed three resident beds that lacked mattress covers. |
Yes |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
(1) of the (2) homes inspected had emergency evacuation and relocation diagrams that did not include designated location outside of the building. Also, the designated meeting place for weather disaster was not included. This is a separate standard, but all designated meeting areas for emergency evacuation should be included on the diagram. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During the walkthrough, I observed the following physical site issues to be in compliant: A shower head in one of the resident bathrooms was broken and needed replacing, a small closet/storage area door in one of the cottages was broken with exposed nails, the cabinet in the laundry room of one cottage has been broken with a maintenance report on file since 7/27/24, a toilet in one cottage lacked a tank lid with a maintenance report filed 9/2/24. I observed the following to still be deficient and an extension is being granted: shower surround in one bathroom evidenced a peeling backing board above the shower surround,and a broken bathroom door. I observed a new deficiency during my walk through. There wa drywall damage in Vickie's Main half bath. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the investigation inspection, there was mold/mildew observed in the bathroom of the East House and Old Lodge. There was also sheet rock damage observed a bathroom located in the East House. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the inspection, I observed two beds without protective mattress covers. The operation replaced the mattress covers during the inspection. |
Yes |
| 4 | — |
748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers
The purpose of this rule is to protect the health, safety and well being of children in care by ensuring that caregivers are provided and are informed of all the child's needs, medical conditions and any other information of the children they are supervising. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
In reviewing the documentation and investigation interviews, I observed that the operation failed to report the serious accidental injury of a resident within 24 hours. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A Staff Member was provoking / antagonizing the child in care by raising her voice and saying things such as ?oh your pissed off, there?s the door? and ?your mad at me so why don?t you hit me. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During the DFPS investigation, it was discovered the operation failed to properly supervise children in care, resulting in the children being able to "cheek" medications as well as crushing and snorting medications brought home from the hospital. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly.
During the investigation inspection, there was a jug of mop solution located under the kitchen sink, unlocked, in the New Lodge Home. |
— |
| 3 | — |
748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing
During the walkthrough, I observed that one of the fire extinguishers in a resident cabin lacked a tag or documentation denoting when it was last serviced. The operation replaced the fire extinguisher during the walkthrough with one that was properly tagged. |
Yes |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the inspection, I observed a cottage cabinet with a hole broken through it that staff reported being there over two weeks. The lights in the laundry room of one cabin were burned out and were replaced by the operation during the walkthrough. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, staff initiated restraints for in non-emergency situations. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the walkthrough, I observed two freezers in one of the houses has replaced the missing thermometers. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During the monitoring inspection, it was observed that two children's medication record and actual medication count did not match. The medication record reflected there were 4 doses remaining while the package only contained 2 doses and another child's medication record indicated 3 doses remaining but the package contained 4 doses. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During the monitoring inspection, it was observed that two children's medication record and actual medication count did not match. The medication record reflected there were 4 doses remaining while the package only contained 2 doses and another child's medication record indicated 3 doses remaining but the package contained 4 doses. |
— |
| 4 | — |
748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit
During the investigation inspection, it was discovered that New Lodge had a used fire extinguisher. According to staff and documentation the fire extinguisher was used eight days prior, and a request was submitted for a new one; however, the extinguisher for this Lodge has not been replaced yet. |
— |
| 4 | — |
748.303(a)(2)(A) - Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
The operation failed to report a child in care was taken to the hospital for an allergic reaction to a known nut allergy, that warrant treatment by a medical professional. |
— |
| 3 | — |
748.2855(a)(5) - EBI Documentation-Must include the date and time the intervention was administered
Six out of the eight emergency behavior interventions records reviewed showed no time of the incident. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection, we observed three of four children's medication records to include medication logs with initials for ther person administering medications but not the full names of those individuals. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member failed to secure a box of over-the-counter medication stored in the staff office, resulting in a resident accessing and ingesting the medication without supervision. |
— |
| 2 | — |
748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children
During the investigation inspection, it was observed the four showers located in the East House only had lukewarm/room temperature water for the children to shower. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
During the investigation inspection, there was a first aid kit stored, unlocked and accessible to children, in the bathroom of the East House. The first aid kid contained topical creams and cold compress both of which were labeled to keep out of reach of children. |
Yes |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the inspection, I observed a cottage cabinet with a hole broken through it that staff reported being there over two weeks. The lights in the laundry room of one cabin were burned out and were replaced by the operation during the walkthrough. |
— |
| 3 | — |
748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers
During the walkthrough, we observed two bathrooms lacking handtowels in the restrooms. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
Licensing was not notified within 24 hours of a child's diagnosed fracture. The diagnosis was provided on 5/29/2025 at approximately 530pm, however, the report to SWI did not occur until 5/30/2025 at approximately 630pm. |
— |
| 4 | — |
748.2551(f) - EBI Implementation-If child doesn't understand what to do to be released, caregiver re-explains every 15 minutes until child understands or released
Two of the eight emergency behavior intervention records reviewed showed that caregivers failed to re-explain every 15 minutes what the child needed to do in order to be released from the intervention. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, I observed three refrigerator thermometers reading in excess of the permitted 40 degrees, and one deep freeze unit lacked a thermometer. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
This deficiency was noted as part of a DFPS investigation. |
— |
| 5 | — |
745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone
During the inspection, I observed that one of the maintenance staff hired on 5/1/23 does not have an initial background upon hire with the facility. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the monitoring inspection, one child's medication record was reviewed and observed to be missing the full name of the person who administered the medication. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the investigation inspection, the thermometer located in the East House freezer indicated the freezer was at 16 degrees Fahrenheit, and not at the required 0 degree Fahrenheit or below. Additionally, the thermometer located in Vickie's House refrigerator indicated the refrigerator was at 45 degrees Fahrenheit, and not at the required 40 degree Fahrenheit or below. |
— |
| 4 | — |
748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply
This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member utilized restraint as a means to gain compliance from a child that refused to leave a peer's room. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly.
During the investigation inspection, there was a jug of mop solution located under the kitchen sink, unlocked, in the New Lodge Home. |
— |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
In 4 of 4 records reviewed there was not a documented notice given for the child service planning meeting. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the walkthrough, I observed excessive dust and cobwebs and cracked paint near the ceiling in one of the bedrooms. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, staff initiated restraints for in non-emergency situations. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the inspection, I observed one of the beds in a boys cottage lacked a mattress cover. |
— |
| 4 | — |
748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers
The purpose of this rule is to protect the health, safety and well being of children in care by ensuring that caregivers are provided and are informed of all the child's needs, medical conditions and any other information of the children they are supervising. |
— |
| 3 | — |
748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available
During the inspection, I observed one child's initial medical exam was completed 24 days past the 30 days from admission date. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the walkthrough, I observed broken tiles in the upstairs bathroom floor of a girl's house. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the inspection, I observed a drainage issue in the sink of one cottage, a toilet holding human waste that did not cycle when tested in another cabin, and a cracked shower stall in a third cabin. None of these repairs had work orders filed on them at the time of the inspection. |
— |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
(1) of the (2) homes inspected had emergency evacuation and relocation diagrams that did not include designated location outside of the building. Also, the designated meeting place for weather disaster was not included. This is a separate standard, but all designated meeting areas for emergency evacuation should be included on the diagram. |
— |
| 3 | — |
748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing
During the walkthrough, I observed that one of the fire extinguishers in a resident cabin lacked a tag or documentation denoting when it was last serviced. The operation replaced the fire extinguisher during the walkthrough with one that was properly tagged. |
Yes |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
During the walkthrough, we observed uncovered food in the refrigerator of one of the cottages. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, I observed a mini fridge in one of the cabins that exhibited a thermometer reading of 50 degrees Fahrenheit. The operation turned down the temperature in the unit during the inspection to correct the temperature. |
Yes |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the inspection, I observed mildew in the wooden shower and bathroom walls and celings of four cottages. A shower in one of the houses exhibited low water pressure. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
During the walkthrough, I observed an open water valve recess outside a cottage lacking a protective cover, creating a tripping hazard. The operation replaced this cover at the time of the inspection. |
Yes |
| 3 | — |
748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor
During the investigation inspection, there was potatoes stored on the pantry floor of New Lodge and Vickie's House. |
— |
| 4 | — |
748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
In one of six employee records reviewed, the caregiver employee did not receive 16 hours of EBI preservice training. Only two hours were documented for the employee in the file. |
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| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During the walkthrough, I observed the following physical site issues to be in compliant: A shower head in one of the resident bathrooms was broken and needed replacing, a small closet/storage area door in one of the cottages was broken with exposed nails, the cabinet in the laundry room of one cottage has been broken with a maintenance report on file since 7/27/24, a toilet in one cottage lacked a tank lid with a maintenance report filed 9/2/24. I observed the following to still be deficient and an extension is being granted: shower surround in one bathroom evidenced a peeling backing board above the shower surround,and a broken bathroom door. I observed a new deficiency during my walk through. There wa drywall damage in Vickie's Main half bath. |
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| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
During the ANE investigation, it was discovered that five of six residents interviewed reported staff cursing and yelling at them. |
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200 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.