Capacity 32. 6-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Staff was observed asleep while supervising children with high-risk behavior putting them in substantial risk of harm. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During inspection it was noticed that medication for a child in care was not logged correctly. There were two medication logs for one medication, stating there were 3 pills left on one log and 28 on another log. The pill card or script card had 1 pill. (CI) |
Yes |
| 4 | — |
748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return
A child's file was reviewed; there was no unauthorized debriefing documentation. The administrative staff were unable to produce to requested documentation prior to the conclusion of the inspection. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Staff on duty were not aware of child's ongoing activity when child got access to prescribed medications and ingested it. Also, staff stated that she did not witness the incident and don't want to speculate about it. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
During forensic interview, victim child alleged to have been chock by the aggressors during while sexually been assaulted. Victin child stated alleged to not been able to breath while being chocked. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
A staff member violated the operations' Appropriate Boundaries and Relationships/Staff Resident Relationships Policy, Sexual Misconduct Policy, and Conflict of Interest Policy when engaging in an inappropriate relationship with a child in care while under the auspices of the operation. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
Several Serious Incident reports did not have the facility address and the telephone number. |
— |
| 2 | — |
748.2151(g) - Medication record-medication records of prescription & non-prescription medication dispensed to the child must be incorporated into child's record
Four of four records did not include their past medication records. |
— |
| 3 | — |
748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any
Serious incident reports received are missing pertinent information. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One medication, prescribed by a healthcare professional, was not administered to the child in care. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
The operation did not make a prudent judgement when placing camera in to bedrooms without prior approval from treatment team. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Staff failed to provide adequate supervision to children which resulted to a child gaining access to prescribed medications. |
— |
| 3 | — |
748.303(e)(2)(A) - Serious Incident-Report to Licensing no later than 24 hours after disaster or emergency that requires an operation to close
Resident in care was taken to dental office for dental repair and not reported within the required time frame. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of one childs file today, date of birth in the childs initial service plan and pre liminary service plan has it as January 16th while the date of birth for the child in the childs biography cover page has it as January 6th but has same year of birth. |
Yes |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of one child file today, multiple date of birth was noted. The date of birth in the children list is different from the date of birth in the childs behavior managment plan. The date in the children list says 14 while the date in the behavior management plan says 12. Citation was corrected at inspection. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Multiple sources reported witnessing staff sleeping or resting their eyes while supervising children including children with high risk behaviors. |
— |
| 3 | — |
748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
One of four caregivers started in 2020 but his TB test was from 2013. It was not indicated in his employee binder that he previously worked for any other RTC/GRO/CPA. |
— |
| 4 | — |
748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave
During walkthrough of kitchen, it was noticed that meat in the refrigerator was not properly thawed. Food was seen opened and bleeding on a sliver pan in the refrigerator. Photo was taken. (CI) |
Yes |
| 4 | — |
748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child
A child in care inflicted cuts on her arm during a crisis situation on 08/24/2023, this was not reported to Licensing until 08/30/2023. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Investigation interviews indicate care givers became aware on 09-18-2022 of allegations of a care giver being sexually in appropriate in the presence of children in care and there was a miscommunication among the care givers resulting in this care giver being able to return to work with no restrictions or precautions in place until 09-19-2022 when an additional similar allegation prompted the operation to implement a plan. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
It was determined a staff member has fallen asleep while being responsible for children in care with significant high risk behaviors. |
— |
| 5 | — |
748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously
According to the operation, a child in care was asked to write a statement regarding a report made by the child in an effort to not put anyone in any type of litigation. |
— |
| 2 | — |
748.3353(b)(2) - Video cameras only used to supervise children when specific criteria met. Document justification in child's service plan & ensure alternative privacy
The operation placed video cameras in the bedrooms and therapy room without prior approval from each girls treatment team per minimum standards. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
It was found that a child was not provided a prescribed pre diabetic medication for a month due to the medication not being delivered. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on June 15, 2026, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2)12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring necessitating previous extension. Furthermore, due to the recent citation issued on April 8, 2026, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on April 8, 2026. Specifically, the operation was cited for standard 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention. The operation met compliance on 4/22/2026. - Operation failed to satisfy the conditions of the plan - Operation was unable to meet compliance with Medium-High or High weighted licensing citations - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, including having open investigations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $150. |
— |
| 3 | — |
748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation
During a Heighted monitoring visit, it was observed that medication was being prepped 4 hours prior to being administered. It was also reported by the LCCA that medication is prepped 1 1/2 to 2 hours prior to being administered. |
— |
| 2 | — |
748.3353(b)(2) - Video cameras only used to supervise children when specific criteria met. Document justification in child's service plan & ensure alternative privacy
Records reviewed on all six residents. There was not an individualized statement within each child's service plan indicating the need of a camera within the bedrooms. |
— |
| 3 | — |
748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
Upon review of the personnel records, one of the caregiver was missing an affadavit. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
In an investigation conducted by DFPS, it was confirmed that an employee did not appropriately supervise children in care when starting a personal relationship with two children in care while working at the operation. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the review of one staff file, the last Truama Training taken by staff was 4-12-23. No Evidence that the Truama training has been taken in 2024 by staff |
— |
| 3 | — |
748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services
1 out of 4 files reviewed does not have a signature of the treatment director |
— |
| 1 | — |
748.1339(a)(2) - Initial Service Plan-Team must include person designated to make decisions regarding a child's participation in childhood activities
Four of four records reviewed did not contain a signature from the DFPS caseworker. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The Administrator failed to mention the injury sustained by a resident (a brace on her right wrist for 7 days), as a result of a physical altercation, when she made a report to the Abuse and Neglect hotline. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
One prescribed medication was not included in the child in care's discharge paperwork. |
— |
| 5 | — |
748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard
During the walk through of the facility it was noticed that two bunkbeds did not have a bedrail on the top bunk |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
It was determined that a staff members name was forged on a document. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the review of one staff file, different dates of hire was noticed in the staff file. One of the date of hire is 8-14-23 while the other date of hire says 8-28-23. Also, during the review of one childs file, 2 dates of birth was noticed. One of the date says 4-13-24 while the other says 4-13-10. Both errors were corrected at inspection. |
Yes |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The unauthorized absence log was observed missing the required information. The log was also observed with untrue/inaccurate information documented. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk through it was observed that 5 beds were missing cover protectors in the girls unit. |
Yes |
| 5 | — |
748.2001(a) - Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications
During the course of the investigation, it was determined that consent was not obtained for medication. |
— |
| 3 | — |
748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
The reports are not detailed in what interventions the caregivers actually used. It is mostly stated that staff redirects the children but does not specify how. For a fight, it was stated that the residents were separated but does not specify how. |
— |
| 4 | — |
748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.
It is documented that a child in care inflicted cuts on her arm on 08/24/2023, there is no documentation showing that a suicide screening was administered. |
— |
| 4 | — |
748.303(a)(5)(A) - Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child
Victim Child alleged that staff were aware of the incident where residents had nonconsensual sex inside the facility and did not report it., did not take her to the hospital and did not notify law enforcement. |
— |
| 3 | — |
748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.
It was determined that suicide screening was not administered for a child during admission. |
— |
| 4 | — |
748.191(3) - Required Postings-Post emergency and evacuation relocation plans in each building and living quarters used by children where all may view them
Upon inspection of facility the evacuation plan was not posted in any of the units or around the facility (CI) |
Yes |
| 3 | — |
748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest
The purpose of this rule is to ensure the privacy of the child while in therapy. During the inspection, a camera was observed in the therapy room and requested to be remove prior to leaving the operation. The operation did remove the camera in the therapy treatment room prior to licensing leaving the inspection. |
— |
| 3 | — |
748.535(3)(F) - Child-care administrator responsibilities-Ensuring that operation complies with applicable rules of chapter 748 and other applicable rules and laws.
The administrator was made aware of a child in care not receiving a prescribed medication but the child in care was still not receiving the medication two weeks after meeting. |
— |
| 3 | — |
748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.
Operational employees did not notify Licensing of police responding to an incident at the operation. |
— |
| 4 | — |
748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions
Lettuce was observed in the refrigerator that was brown and slimy with a label of 8/3/2025. |
Yes |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
Staff did not have medication in a locked container nor inaccessible to children. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on December 9, 2024, it was determined that: (1) Your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: Your operation received a Medium-High weighted citation in a pattern/trend category on November 27, 2024. Specifically, the operation was cited for 748.2003(b)(3)-Administration of prescription medication. The operation has not met compliance. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
— |
| 3 | — |
748.363(4) - Personnel records-Personnel records-Include current job description.
During the review of one staff file today, the job description for the staff was misssing in the file. Inspector was not able to locate job description in the file. The administrator also reviewed the staff file in presence of the inspector and did not find the staff job description. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
According to information in the Serious Incident report, it stated that victim child did not need any medical care. However, child was taken to HCA ER and was prescribed pain medications to be administered as needed and also recommended to follow up with PCP |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
A caregiver used profane language and directed it toward a child in care when speaking to the child. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
Child was prescribed 2 medications during her visit with the doctor, operation staff confirmed during interview that he received the medication from the pharmacy but did not administer medications to the child because they were waiting for approval from CVS caseworker |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on December 12, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on September 25, 2025. Specifically, the operation was cited for standard 748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions. The operation met compliance on 9/25/2025. - Operation failed to satisfy the conditions of the plan - Operation was unable to meet compliance with Medium-High or High weighted licensing citations - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, including having open investigations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $150. |
— |
| 1 | — |
748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event
Four of four records reviewed did not contain a copy of the admission assessment, preliminary, or daily progress notes. Three of the four records did not have any updated incidents reports from 2022. |
— |
| 5 | — |
748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
During the walk through of the facility it was noticed that doors were broken, graffiti was on the unit walls/ doors, and walls were not in good repair |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
It was determined that a staff member neglected to appropriately supervise children with high-risk behaviors. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Program Manager stated in her interview that she prefills the medical form 2403. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A caregiver pulled the hair of a child in care, grabbed the child by the neck and threatened the child. |
— |
| 3 | — |
748.1337(b)(1)(D)(viii) - Initial Service Plan-Include instructions to caregivers about actions to take or conditions to be aware of in order to meet child's special needs
One prescribed medication was not listed in the child in care's service plan. |
— |
| 5 | — |
748.125(e)(1)(A) - You must immediately refer a child to a MH professional for a suicide risk assessment if screening finds child to be at a high risk for suicide.
A child in care suffered self-inflicted cuts to her arm on 08/24/2023 and was not seen by a medical professional until 08/28/2023 where the determination was made to admit her into a behavioral hospital for evaluation. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk through it was observed that 5 beds were missing cover protectors in the girls unit. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Investigation interviews indicate care givers became aware on 09-18-2022 of allegations of a care giver being sexually in appropriate in the presence of children in care and there was a miscommunication among the care givers resulting in this care giver being able to return to work with no restrictions or precautions in place until 09-19-2022 when an additional similar allegation prompted the operation to implement a plan. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on December 12, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on September 25, 2025. Specifically, the operation was cited for standard 748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions. The operation met compliance on 9/25/2025. - Operation failed to satisfy the conditions of the plan - Operation was unable to meet compliance with Medium-High or High weighted licensing citations - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, including having open investigations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $150. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the review of one staff file, the last Truama Training taken by staff was 4-12-23. No Evidence that the Truama training has been taken in 2024 by staff |
— |
| 4 | — |
748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave
During walkthrough of kitchen, it was noticed that meat in the refrigerator was not properly thawed. Food was seen opened and bleeding on a sliver pan in the refrigerator. Photo was taken. (CI) |
Yes |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
During forensic interview, victim child alleged to have been chock by the aggressors during while sexually been assaulted. Victin child stated alleged to not been able to breath while being chocked. |
— |
| 3 | — |
748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services
1 out of 4 files reviewed does not have a signature of the treatment director |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
In an investigation conducted by DFPS, it was confirmed that an employee did not appropriately supervise children in care when starting a personal relationship with two children in care while working at the operation. |
— |
| 1 | — |
748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event
Four of four records reviewed did not contain a copy of the admission assessment, preliminary, or daily progress notes. Three of the four records did not have any updated incidents reports from 2022. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Staff on duty were not aware of child's ongoing activity when child got access to prescribed medications and ingested it. Also, staff stated that she did not witness the incident and don't want to speculate about it. |
— |
| 4 | — |
748.191(3) - Required Postings-Post emergency and evacuation relocation plans in each building and living quarters used by children where all may view them
Upon inspection of facility the evacuation plan was not posted in any of the units or around the facility (CI) |
Yes |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
Child was prescribed 2 medications during her visit with the doctor, operation staff confirmed during interview that he received the medication from the pharmacy but did not administer medications to the child because they were waiting for approval from CVS caseworker |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
The operation did not make a prudent judgement when placing camera in to bedrooms without prior approval from treatment team. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The unauthorized absence log was observed missing the required information. The log was also observed with untrue/inaccurate information documented. |
— |
| 3 | — |
748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation
During a Heighted monitoring visit, it was observed that medication was being prepped 4 hours prior to being administered. It was also reported by the LCCA that medication is prepped 1 1/2 to 2 hours prior to being administered. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
It was determined that a staff members name was forged on a document. |
— |
| 4 | — |
748.303(a)(5)(A) - Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child
Victim Child alleged that staff were aware of the incident where residents had nonconsensual sex inside the facility and did not report it., did not take her to the hospital and did not notify law enforcement. |
— |
| 3 | — |
748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
Upon review of the personnel records, one of the caregiver was missing an affadavit. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During inspection it was noticed that medication for a child in care was not logged correctly. There were two medication logs for one medication, stating there were 3 pills left on one log and 28 on another log. The pill card or script card had 1 pill. (CI) |
Yes |
| 3 | — |
748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.
It was determined that suicide screening was not administered for a child during admission. |
— |
| 5 | — |
748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously
According to the operation, a child in care was asked to write a statement regarding a report made by the child in an effort to not put anyone in any type of litigation. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
It was determined that a staff member neglected to appropriately supervise children with high-risk behaviors. |
— |
| 3 | — |
748.1337(b)(1)(D)(viii) - Initial Service Plan-Include instructions to caregivers about actions to take or conditions to be aware of in order to meet child's special needs
One prescribed medication was not listed in the child in care's service plan. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
One prescribed medication was not included in the child in care's discharge paperwork. |
— |
| 3 | — |
748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any
Serious incident reports received are missing pertinent information. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Staff was observed asleep while supervising children with high-risk behavior putting them in substantial risk of harm. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the review of one staff file, different dates of hire was noticed in the staff file. One of the date of hire is 8-14-23 while the other date of hire says 8-28-23. Also, during the review of one childs file, 2 dates of birth was noticed. One of the date says 4-13-24 while the other says 4-13-10. Both errors were corrected at inspection. |
Yes |
| 4 | — |
748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions
Lettuce was observed in the refrigerator that was brown and slimy with a label of 8/3/2025. |
Yes |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on December 9, 2024, it was determined that: (1) Your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: Your operation received a Medium-High weighted citation in a pattern/trend category on November 27, 2024. Specifically, the operation was cited for 748.2003(b)(3)-Administration of prescription medication. The operation has not met compliance. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
— |
| 5 | — |
748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard
During the walk through of the facility it was noticed that two bunkbeds did not have a bedrail on the top bunk |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Staff failed to provide adequate supervision to children which resulted to a child gaining access to prescribed medications. |
— |
| 5 | — |
748.2001(a) - Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications
During the course of the investigation, it was determined that consent was not obtained for medication. |
— |
| 5 | — |
748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
During the walk through of the facility it was noticed that doors were broken, graffiti was on the unit walls/ doors, and walls were not in good repair |
— |
| 4 | — |
748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return
A child's file was reviewed; there was no unauthorized debriefing documentation. The administrative staff were unable to produce to requested documentation prior to the conclusion of the inspection. |
— |
| 3 | — |
748.303(e)(2)(A) - Serious Incident-Report to Licensing no later than 24 hours after disaster or emergency that requires an operation to close
Resident in care was taken to dental office for dental repair and not reported within the required time frame. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of one childs file today, date of birth in the childs initial service plan and pre liminary service plan has it as January 16th while the date of birth for the child in the childs biography cover page has it as January 6th but has same year of birth. |
Yes |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The Administrator failed to mention the injury sustained by a resident (a brace on her right wrist for 7 days), as a result of a physical altercation, when she made a report to the Abuse and Neglect hotline. |
— |
296 inspection record(s) on file from TX-HHSC.