Child care center ·
5833 OAKBEND TRL, Fort Worth, TX 76132-3910 ·
License 1693628
Capacity 128. 11-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.1101(b)(3)(F) - Children's rights-to personal care, hygiene, and grooming equipment and supplies and training in how to use them
All children in care are not allowed to shave. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
Treatment plans indicated that children must be observed every 15 minutes by staff members. These instructions were not followed. |
— |
| 4 | — |
748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication
Employee who has not completed medication administration training has given medication to a child in care. |
— |
| 1 | — |
748.1437(2) - Discharge/Transfer Documentation-Must include date and time the child was informed of his discharge or transfer
Discharge documentation did not discuss when the child was informed of discharge or transfer. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
2 service plans reviewed were not completed in 72 hours. |
Yes |
| 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 engaged in tickling, touching, and hugging of children in care without consent. The staff member's actions were indicated to make children uncomfortable. |
— |
| 2 | — |
748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs
Child?s preliminary service plan does not describe how the operation will meet the child?s medical needs or follow-up plan for possible side effects. |
— |
| 3 | — |
748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
Children in care were allowed to remain in the same proximity when children were restrained, which resulted in a restrained child being kicked. |
— |
| 2 | — |
748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours
2 of 6 employee files reviewed had suicide prevention training that did not include the number of training hours on the certificates. |
— |
| 5 | — |
745.8641 - Requirements during probation
5 out 15 probation conditions were not met. Condition #1: Met Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: the training was not due per conditions. Condition #8: Did not meet - trainings not completed with all staff by the due date of 4/12/2023; Condition #9: Did not meet - 18 staff members did not complete trainings by 03/26/2023; Condition #10: Did not meet - 13 staff members trainings were not completed by 3/26/2023; Condition #11: Met Condition #12: Met Condition #13: Met Condition #14: Did not meet - one child file did not have parent notification; Condition #15: Met |
— |
| 3 | — |
748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Two children in care (15 and 17 years of age) were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity. |
— |
| 2 | — |
748.153(2)(A) - Notification - At least 15 days in advance - Changes to policies and procedures required by 748.103(b)
EBI training for SAMA began as of 12/29/22. This technique was not submitted for approval prior to implementation. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition #1: The program evaluation submitted is a check list, that provides rating of each criterion. It does not provide information to the reader on how each determination was made. Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Medication policies state a specified person will administer medication, medication file was observed to have multiple nurses administer medication to a child in care. Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13:This condition is considered not met because the date of correction is not being documented on the audit form. Condition #14: Met Condition #15: Met |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A caregiver did not follow the operation's policy and procedures for redirecting child behaviors. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
A child placed on 12/02/22 did not have a completed service plan as of inspection date 1/18/23. |
Yes |
| 5 | — |
748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
There were three rooms with graffiti on the walls. |
— |
| 4 | — |
748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children
The operation was out of ratio when a unit of 11 children were left in the care of 2 caregivers, when 3 caregivers were required. One child was indicated to be on one-on-one supervision. The Administrator did not ensure the operation had sufficient staff to care for children in care. An acting administrator left the facility and did not provide a plan to mitigate risk to children while the unit was out of ratio. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition #1 - Met Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Not Met Condition #12 - Met Condition #13 - Met Condition #14 - Met Condition #15 - Met |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
An employee with an inactive background check was on property at the time of the inspection. |
Yes |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
During sleeping hours, a child in care entered multiple rooms several times without staff's knowledge. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
This standard was found deficient as part of a DFPS Investigation. |
— |
| 5 | — |
748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint
A caregiver implemented a personal restraint, prior to being trained in EBI. |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
A medication was observed stored in a small cup and not in the original container. The medication was not being administered at the time of observation. The medication was originally stored in a blister pack and was left in this cup due to the child refusing to take it in the morning. |
Yes |
| 1 | — |
748.1349(b)(2) - Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign
Three service plans did not have signatures of the child. |
— |
| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
The operation had one caregiver for 6 children who were receiving treatment services. During this time a serious incident occurred |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Clinical Progress Logs documents that children were observed by staff members when they were not. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition # 1: Pending - extention granted to 7/10/23. Condition #2: Met Condition #3: Not Met - operation did not complete a new comprehensive assessment for a rehired employee Condition #4: Met Condition #5: Met Condition #6: Not Met - Employee administered medication before completing medication training requirement per the condition Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition. Condition #14: Met Condition #15: Not Met - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617. |
— |
| 3 | — |
748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
A restraint that lasted 3 to 5 minutes was not documented. |
— |
| 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.
Youth-in-care did not receive a new Suicide Full Assessment when admitted to care. |
— |
| 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
An admissions assessment completed on 01/21/23 documents that a child was abused. The information was not reported as required. |
— |
| 3 | — |
748.363(4) - Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position
2 nursing staff files did not contain a license. |
— |
| 4 | — |
748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required
The service plan for the youth documented a general statement for supervision and did not discuss his employment or the specific needs of the youth. |
— |
| 4 | — |
748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
Two children in care who had a history of sex trafficking and run-away behavior were allowed to go for a walk and eventually ran away. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The 6 month's unauthorized absence evaluation was requested at inspections conducted on 01/18/23 and 01/24/23. This document was not provided. |
— |
| 2 | — |
748.361(a) - Personnel records - All active records maintained at the operation
Several employee files did not contain verification for how job requirements were met. 1 employee's resume and degree was emailed to support verification after the inspection was complete. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
A child in care was under the influence of a substance, was behaving abnormally, and was not separated from the group during therapy. |
— |
| 3 | — |
748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
No effort was made to provide privacy to a child that was restrained by two staff in front of 8 other children. |
— |
| 3 | — |
748.3443(a)(5) - Food Preparation-Food items must be refrigerated immediately after use & after meals, if the food requires refrigeration
A refridgerator near the serving area in the cafeteria was found to be unplugged and contained a package of spoiled, molded food. |
Yes |
| 3 | — |
748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan
Two children at the operation were not supervised in accordance with the information that is described and documented in each child' s individual service plan. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
Caregivers did not provide appropriate supervision and environment to children when an acting administrator and supervisor on duty left one caregiver to care for 10 children. Children in care engaged in a physical altercation and the single caregiver was unable to de-escalate the physical altercation and ensure child safety. As a result, one child sustained a significant physical injury. The ratio required at the time of the incident was to be 1 caregiver to every 5 children. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
A staff member yelled at a child in care. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
A staff failed to provide appropriate supervision and monitor vitals for a 16 year old youth and a 17 year old youth after they ingested several non-prescribed over the counter medications. |
— |
| 3 | — |
748.607 - Treatment Director-If more than 1 treatment service provided, can have 1 treatment director if qualifications met for the most prevalent services
37 children were in placement. Of the 37 children placed 14 children were receiving services for emotional disorders (38%). At the time of the inspection, the Treatment Directors named did not meet the rule requirement. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
1 of 1 medication log did not provide a reason medication was prescribed. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
4 of 4 medication logs were missing the medication pill count. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A child with previous aggressive behavior was able to engage in a second altercation with another child in care. |
— |
| 2 | — |
748.2853(4) - EBI Documentation-Content of the post discussion, if applicable
On 11 of 11 EBI reports reviewed there was no post restraint discussion documented |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Children in care were allowed to have personal cell phone devices. This process was not according to policy. |
— |
| 3 | — |
748.363(11) - Personnel records-Include record of training and training hours
2 of the 15 files reviewed did not contain a record of training taken by the employee. |
— |
| 4 | — |
748.507(2) - Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator
A staff member did not report a sexual assault of the two children in care. The operation was also informed that 3 staff members' actions may have neglected children in care. The operation did not report any of these incidents to statewide intake. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
There was a toilet that was clogged and was not in working order. |
Yes |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt. |
— |
| 4 | — |
748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection
Operation health inspection was not completed 12 months from the last inspection. The last health inspection was completed 10/23/2023. |
— |
| 3 | — |
748.303(a)(12)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child any suicide attempt by their child.
A child in care attempted suicide and the operation did not document the how the parent was notified. |
— |
| 3 | — |
748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
The operation documents a serious incident report as a incident report. |
— |
| 2 | — |
748.1437(7) - Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction
Discharge summary does not include child's reaction to discharge. |
— |
| 3 | — |
748.363(1) - Personnel records-Include date of employment
2 of 4 employee files did not include date of employment. |
— |
| 3 | — |
748.363(4) - Personnel records-Personnel records-Include current job description.
2 of 4 employee files does not include job description for current job title. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
A restraint was implemented on 02/07/2023. The documentation of the restraint is incongruent with what was observed on the video. |
— |
| 1 | — |
748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals
A licensed professional was not involved in the development of 1 child's service plan. The child was identified to receive treatment services for emotional disorders. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child in care was left unsupervised during a one-on-one supervision resulting in suicide attempt. |
— |
| 5 | — |
748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously
Staff interfered with a child's attempt to make a complaint over the phone by not allowing privacy and refusing requests for privacy. Additionally, staff regularly listen to or monitor children's phone calls |
— |
| 3 | — |
748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record
2 of 2 child files reviewed did not indicate signatures from the children being admitted. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
Medication log pill count shows a child was given more medication than instructed. |
— |
| 5 | — |
748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers
A caregiver was providing a child with tobacco products. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
Policy and procedures require that only an LVN, RN or medication aide administered medication to children in care. This procedure was not followed. |
— |
| 4 | — |
748.125(e)(2)(E) - You must adhere to recommendations of the MH professional and update the child?s safety/service plan's if child is a potential risk for suicide.
In reviewing the admission assessment, youth-in-care assessment of suicide potential was high and intervention plan was not properly implemented. |
— |
| 5 | — |
748.2605(b)(2) - Personal Restraints Prohibited-Prone and supine restraints except as a last resort when other less restrictive interventions have proven ineffective
A child in care was placed in a supine restraint for several minutes. There was no indication that this position was the most effective technique. |
— |
| 4 | — |
748.981(c) - First-aid-CPR training-Any new caregiver not currently certified in first-aid must be trained and certified within 90 days of employment
One out of two staff files reviewed did not have first aid training. The staff member received the training for first aid on 8/31/2021. The staff member is current. |
Yes |
| 3 | — |
748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
The operation could not produce EBI documentation from April or May 2022 and reported that they did not keep documentation for EBI that was performed prior to June 2022. Additionally the operation produced 11 EBI reports for June 2022, of which 9 did not include the specific technique of EBI performed, 8 did not include the length of time the EBI was performed for, and 10 did not document when the staff explained the behaviors necessary for the child to be released from a restraint. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
A child was restrained multiple times in a day, with 6 or 7 staff members surrounding the child, escalating the situation. |
— |
| 3 | — |
748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
11 of the 15 records reviewed did not meet the requirement. Specifically, 4 affidavits were incomplete, and 7 affidavits were not notarized or were missing from the record. |
— |
| 2 | — |
748.1101(b)(3)(L) - Children's rights-Based on child's age/maturity seek employment, keep own money/bank acct, paid for work done at op except for chores as discipline
A youth's job was threatened by a staff member as discipline. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
Two staff performed a restraint on a child for a situation that was not considered an emergency. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
There was one bathroom that had a hole in the wall. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
There is a video footage of a child leaving the cafeteria to attack another child at the facility. There were two staff standing in the doorway and did not intervene. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A staff member pushed a child against a wall as a form of discipline. |
— |
| 3 | — |
748.1101(b)(6)(A) - Child rights-medical,dental,vision,MH,develp services that meet child need. Right to request services separate from adults who receive services
A child in care did not receive therapy as per service plan. It later lead to the child in care engaging in self harming and destructive behavior. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
5 Medication logs did not have prescribing doctor listed. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
After receiving two children into care, a staff member took two children to an unauthorized location. She had the children shower after a sexual assault before returning them to the operation. This staff member also allowed one of the children to leave with an unauthorized person. |
— |
| 2 | — |
748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
5 of 5 child files did not have immunization records. |
— |
| 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 physically fought with a child and had to be held back by another staff to stop the conflict. |
— |
| 4 | — |
748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child
A child's suicide attempt was not reported as required by minimum standards. |
— |
| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
One caregiver was responsible for eight children when a physical altercation broke out between two children in care. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition #1: Met Condition #2: Met Condition #3: Not Met - 11 out of 30 employees hired or rehired did not have a comprehensive assessement. Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - 5 of 5 service plans audits were missing required documentation. Condition #14: Met Condition #15: Met |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition #1: Progress reviews for the improvement plan were not available for review. Condition #12: Changes to the personnel file audit were not observed or that the personnel file was still missing the job description, person responsible for the changes, due date, and correction date. |
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| 1 | — |
748.1703(b) - Menus-must document food substitutions on the menu that are of comparable food value
Menus do not document substitutions. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
5 Medication logs did not have a pill count or inventory listed. |
— |
| 3 | — |
748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
Child was observed to have redness to the armpit area and seen by the facility nurse. The medical encounter was not documented as required on an incident report. |
— |
| 5 | — |
748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
A child was not taken to receive medical care twice for severe abdominal pain. Their parent was called to take the child to receive medical care instead. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
A caregiver solicited images, videos, and encouraged sexualized activities from a 13, 16, and 17 year old children in care. |
— |
| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
The operation was out of ratio when two caregivers were left to care for 11 children. The operation continued to be out of ratio when one caregiver was left to care for ten children. |
— |
| 3 | — |
748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered
Serious incident report does not indicate the specific emergency behavior technique. |
— |
| 5 | — |
HRC42.04412(a) - Interference with an investigation
The operation did not provide the videos requested by the Investigator pertaining to a particular employee. |
— |
| 4 | — |
748.1113(c)(3) - Child Rights searches-RTC or emergency care services program may conduct routine searches if only outer clothing is removed (shoes, coats, hats)
The operation is performing routine searches for residents that require the removal of all clothing. |
— |
| 2 | — |
748.989(b)(4) - Documentation of first-aid and CPR certification-Includes the trainer's name and qualifications
Two of the CPR certificates reviewed did not have the trainer name, qualifications and the length of hours. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
The caregiver did not use good judgment when they did not follow the operations procedures in not allowing children of the opposite sex to be together. This resulted in two children acting inappropriately together. |
— |
| 4 | — |
748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
Concerns of abuse of a child in care by was not reported within timeframes. |
— |
597 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.