Capacity 24. 7-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
One window in the children room was found during the walkthrough to be damaged. Window glass was not properlly sealed and had opening which may result to insects / resptiles crawling inside the room from outside thereby posing safety concern to the children. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
2 residents physically assaulted one resident at the facility which resulted to the victim child sustaining concussion and head fracture. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
There was an inconsistency between the annual AWOL log and incident report regarding a resident AWOL. |
— |
| 4 | — |
748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required
Child's service plan does not clearly document the child's supervision needs, but instead is generalized. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the walkthrough of the East building, one damaged window blind was observed in one resident toilet. Maintenance staff was able to replace the damaged blind during inspection. |
Yes |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
During the review of one childs file today, it was noted that the invite to DFPS caseworker for the initial service plan meeting was not sent timely. Initial service plan was completed on 6-2-24 while the invite was sent on 6-3-24 a day after the plan meeting was completed. |
— |
| 4 | — |
748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model
One of five child records reviewed was found to be missing the medication administration record from a medication administered the night of the 12/28/23. |
— |
| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
During todays walkthrough at the East building kitchen, one pack of bread was found to be open as the wrap was not sealed. TA was issued to the operation for this same standard during the last HM inspection on 2-22-24. |
Yes |
| 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
Chicken was being thawed out in the sink. |
Yes |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
It was observed during the walkthrough of the East Campus that one of the children restroom has damaged tile on the wall and staff were not aware of the damage and no work order was created for the damage. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
The child's service plan required a Safety Plan to be implemented to address his aggressive behaviors, particularly his pattern of targeting younger peers. The Safety plan was not created as documented. His supervision plan also mandated 1:1 supervision whenever the youth exhibited verbal or physical aggression. Residents and staff reported multiple incidents where the child hit or called younger peers names without provocation. Despite these behaviors, staff only intervened by separating the youth from peers or removing youth from the situation. However, 1:1 supervision was not implemented as required by the service plan following these incidents. |
— |
| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
1 Bag of Krogger Pinto Beans was found to be open with beans inside in the kitchen cabinet during the walkthrough of the Northeast Building. |
Yes |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Staff failed to intervene timely in a physical altercation between children causing one child to sustained significant injuries. |
— |
| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
During the walkthrough of the facility, one of the beds in the children room in East building was observed without a pillow case and no sheet. This was corrected at inspection. |
Yes |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
It was observed that all beds did not have a required mattress covering or protector. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One of the children?s incident reports states that the child left through the front door, which contradicts information gathered from staff and resident interviews. According to the interviews, the child left through his bedroom window, and his absence was not discovered until staff conducted a headcount. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
It was noticed during the review of one childs medication record that the medication count documentation for 7-17-23 was not accurate. The correct count was suppose to be 48 but the record has 58. Medication record was corrected by the staff that completed it to reflect 48 counts. |
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 November 5, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 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 was issued a corrective action from Residential Contracts, and the corrective action plan was accepted on 6/10/2025. The corrective action contained violations in one or more trend/pattern categories on your Heightened Monitoring Plan. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the review of one staff file, it was observed that staff annual Truama training has expired. Staff took training last on 7-3-23. Staff took training immediately as such citation was corrected at inspection and copy of the training certificate taken. |
Yes |
| 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 determined that the operation did not follow the doctor's orders when it came to stopping a medication, Trileptal, and starting a second dose of Abilify. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
CCI Investigator observed staff sleeping at the facility while on duty and supervising children in care. Administrator was notified of the incident. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
A child was not administered medication as prescribed according to the instructions of the health-care preofessional's orders. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
There is no indication on the medication error documentation as to when it was documented or anything regarding the healthcare physician being contacted. |
— |
| 3 | — |
748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.
During the review of SIR reports, it was observed that the operation called in several serious incident reports involving unauthorize absences of children later than 6 hours from when the absence was discovered according to the time incidents were received by statewide intake in class. Incidents occured on 10-28-23 in investigation #3039668, on 11-3-23 in investigation #3041001 and on 11-5-23 in investigation #3041113 |
— |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
The injury of a child that required medical treatment was not reported to the child's case worker immediately. |
— |
| 4 | — |
748.3231(b)(1) - Evacuation-Plan requires person in charge during emergency to designate an employee to call the fire dept in case of fire, explosion, toxic fumes
The evacuation plan policy did not address who will be designating an employee during an emergency. |
Yes |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
It was observed that all beds did not have a required mattress covering or protector. |
— |
| 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
Chicken was being thawed out in the sink. |
Yes |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
The injury of a child that required medical treatment was not reported to the child's case worker immediately. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
It was observed during the walkthrough of the East Campus that one of the children restroom has damaged tile on the wall and staff were not aware of the damage and no work order was created for the damage. |
— |
| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
During the walkthrough of the facility, one of the beds in the children room in East building was observed without a pillow case and no sheet. This was corrected at inspection. |
Yes |
| 3 | — |
748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.
During the review of SIR reports, it was observed that the operation called in several serious incident reports involving unauthorize absences of children later than 6 hours from when the absence was discovered according to the time incidents were received by statewide intake in class. Incidents occured on 10-28-23 in investigation #3039668, on 11-3-23 in investigation #3041001 and on 11-5-23 in investigation #3041113 |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Staff failed to intervene timely in a physical altercation between children causing one child to sustained significant injuries. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
2 residents physically assaulted one resident at the facility which resulted to the victim child sustaining concussion and head fracture. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
A child was not administered medication as prescribed according to the instructions of the health-care preofessional's orders. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
The child's service plan required a Safety Plan to be implemented to address his aggressive behaviors, particularly his pattern of targeting younger peers. The Safety plan was not created as documented. His supervision plan also mandated 1:1 supervision whenever the youth exhibited verbal or physical aggression. Residents and staff reported multiple incidents where the child hit or called younger peers names without provocation. Despite these behaviors, staff only intervened by separating the youth from peers or removing youth from the situation. However, 1:1 supervision was not implemented as required by the service plan following these incidents. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
One window in the children room was found during the walkthrough to be damaged. Window glass was not properlly sealed and had opening which may result to insects / resptiles crawling inside the room from outside thereby posing safety concern to the children. |
Yes |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
It was noticed during the review of one childs medication record that the medication count documentation for 7-17-23 was not accurate. The correct count was suppose to be 48 but the record has 58. Medication record was corrected by the staff that completed it to reflect 48 counts. |
Yes |
| 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 determined that the operation did not follow the doctor's orders when it came to stopping a medication, Trileptal, and starting a second dose of Abilify. |
— |
| 4 | — |
748.3231(b)(1) - Evacuation-Plan requires person in charge during emergency to designate an employee to call the fire dept in case of fire, explosion, toxic fumes
The evacuation plan policy did not address who will be designating an employee during an emergency. |
Yes |
| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
1 Bag of Krogger Pinto Beans was found to be open with beans inside in the kitchen cabinet during the walkthrough of the Northeast Building. |
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 November 5, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 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 was issued a corrective action from Residential Contracts, and the corrective action plan was accepted on 6/10/2025. The corrective action contained violations in one or more trend/pattern categories on your Heightened Monitoring Plan. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 4 | — |
748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required
Child's service plan does not clearly document the child's supervision needs, but instead is generalized. |
— |
| 4 | — |
748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model
One of five child records reviewed was found to be missing the medication administration record from a medication administered the night of the 12/28/23. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the walkthrough of the East building, one damaged window blind was observed in one resident toilet. Maintenance staff was able to replace the damaged blind during inspection. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
CCI Investigator observed staff sleeping at the facility while on duty and supervising children in care. Administrator was notified of the incident. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the review of one staff file, it was observed that staff annual Truama training has expired. Staff took training last on 7-3-23. Staff took training immediately as such citation was corrected at inspection and copy of the training certificate taken. |
Yes |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
During the review of one childs file today, it was noted that the invite to DFPS caseworker for the initial service plan meeting was not sent timely. Initial service plan was completed on 6-2-24 while the invite was sent on 6-3-24 a day after the plan meeting was completed. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
There is no indication on the medication error documentation as to when it was documented or anything regarding the healthcare physician being contacted. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One of the children?s incident reports states that the child left through the front door, which contradicts information gathered from staff and resident interviews. According to the interviews, the child left through his bedroom window, and his absence was not discovered until staff conducted a headcount. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
There was an inconsistency between the annual AWOL log and incident report regarding a resident AWOL. |
— |
| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
During todays walkthrough at the East building kitchen, one pack of bread was found to be open as the wrap was not sealed. TA was issued to the operation for this same standard during the last HM inspection on 2-22-24. |
Yes |
| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
During the walkthrough of the facility, one of the beds in the children room in East building was observed without a pillow case and no sheet. This was corrected at inspection. |
Yes |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
A child was not administered medication as prescribed according to the instructions of the health-care preofessional's orders. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
The child's service plan required a Safety Plan to be implemented to address his aggressive behaviors, particularly his pattern of targeting younger peers. The Safety plan was not created as documented. His supervision plan also mandated 1:1 supervision whenever the youth exhibited verbal or physical aggression. Residents and staff reported multiple incidents where the child hit or called younger peers names without provocation. Despite these behaviors, staff only intervened by separating the youth from peers or removing youth from the situation. However, 1:1 supervision was not implemented as required by the service plan following these incidents. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
It was noticed during the review of one childs medication record that the medication count documentation for 7-17-23 was not accurate. The correct count was suppose to be 48 but the record has 58. Medication record was corrected by the staff that completed it to reflect 48 counts. |
Yes |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
During the review of one childs file today, it was noted that the invite to DFPS caseworker for the initial service plan meeting was not sent timely. Initial service plan was completed on 6-2-24 while the invite was sent on 6-3-24 a day after the plan meeting was completed. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
One window in the children room was found during the walkthrough to be damaged. Window glass was not properlly sealed and had opening which may result to insects / resptiles crawling inside the room from outside thereby posing safety concern to the children. |
Yes |
| 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 determined that the operation did not follow the doctor's orders when it came to stopping a medication, Trileptal, and starting a second dose of Abilify. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
There was an inconsistency between the annual AWOL log and incident report regarding a resident AWOL. |
— |
| 4 | — |
748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required
Child's service plan does not clearly document the child's supervision needs, but instead is generalized. |
— |
| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
1 Bag of Krogger Pinto Beans was found to be open with beans inside in the kitchen cabinet during the walkthrough of the Northeast Building. |
Yes |
| 4 | — |
748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model
One of five child records reviewed was found to be missing the medication administration record from a medication administered the night of the 12/28/23. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
It was observed during the walkthrough of the East Campus that one of the children restroom has damaged tile on the wall and staff were not aware of the damage and no work order was created for the damage. |
— |
| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
During todays walkthrough at the East building kitchen, one pack of bread was found to be open as the wrap was not sealed. TA was issued to the operation for this same standard during the last HM inspection on 2-22-24. |
Yes |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
There is no indication on the medication error documentation as to when it was documented or anything regarding the healthcare physician being contacted. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the walkthrough of the East building, one damaged window blind was observed in one resident toilet. Maintenance staff was able to replace the damaged blind during inspection. |
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 November 5, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 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 was issued a corrective action from Residential Contracts, and the corrective action plan was accepted on 6/10/2025. The corrective action contained violations in one or more trend/pattern categories on your Heightened Monitoring Plan. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
CCI Investigator observed staff sleeping at the facility while on duty and supervising children in care. Administrator was notified of the incident. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
It was observed that all beds did not have a required mattress covering or protector. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One of the children?s incident reports states that the child left through the front door, which contradicts information gathered from staff and resident interviews. According to the interviews, the child left through his bedroom window, and his absence was not discovered until staff conducted a headcount. |
— |
| 4 | — |
748.3231(b)(1) - Evacuation-Plan requires person in charge during emergency to designate an employee to call the fire dept in case of fire, explosion, toxic fumes
The evacuation plan policy did not address who will be designating an employee during an emergency. |
Yes |
| 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
Chicken was being thawed out in the sink. |
Yes |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
The injury of a child that required medical treatment was not reported to the child's case worker immediately. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
2 residents physically assaulted one resident at the facility which resulted to the victim child sustaining concussion and head fracture. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the review of one staff file, it was observed that staff annual Truama training has expired. Staff took training last on 7-3-23. Staff took training immediately as such citation was corrected at inspection and copy of the training certificate taken. |
Yes |
| 3 | — |
748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.
During the review of SIR reports, it was observed that the operation called in several serious incident reports involving unauthorize absences of children later than 6 hours from when the absence was discovered according to the time incidents were received by statewide intake in class. Incidents occured on 10-28-23 in investigation #3039668, on 11-3-23 in investigation #3041001 and on 11-5-23 in investigation #3041113 |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Staff failed to intervene timely in a physical altercation between children causing one child to sustained significant injuries. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
A child was not administered medication as prescribed according to the instructions of the health-care preofessional's orders. |
— |
| 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 November 5, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 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 was issued a corrective action from Residential Contracts, and the corrective action plan was accepted on 6/10/2025. The corrective action contained violations in one or more trend/pattern categories on your Heightened Monitoring Plan. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
One window in the children room was found during the walkthrough to be damaged. Window glass was not properlly sealed and had opening which may result to insects / resptiles crawling inside the room from outside thereby posing safety concern to the children. |
Yes |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the walkthrough of the East building, one damaged window blind was observed in one resident toilet. Maintenance staff was able to replace the damaged blind during inspection. |
Yes |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
It was noticed during the review of one childs medication record that the medication count documentation for 7-17-23 was not accurate. The correct count was suppose to be 48 but the record has 58. Medication record was corrected by the staff that completed it to reflect 48 counts. |
Yes |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
There is no indication on the medication error documentation as to when it was documented or anything regarding the healthcare physician being contacted. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
One of the children?s incident reports states that the child left through the front door, which contradicts information gathered from staff and resident interviews. According to the interviews, the child left through his bedroom window, and his absence was not discovered until staff conducted a headcount. |
— |
| 3 | — |
748.1101(b)(4)(A)(vi) - Children's rights- To be free from being threatened with the loss of placement or shelter as punishment
Two residents stated that they have heard staff say that they will take them to the hospital due to bad behavior. |
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| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
It was observed that all beds did not have a required mattress covering or protector. |
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| 3 | — |
748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet
During the walkthrough of the facility, one of the beds in the children room in East building was observed without a pillow case and no sheet. This was corrected at inspection. |
Yes |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
The injury of a child that required medical treatment was not reported to the child's case worker immediately. |
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| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
1 Bag of Krogger Pinto Beans was found to be open with beans inside in the kitchen cabinet during the walkthrough of the Northeast Building. |
Yes |
| 4 | — |
748.3231(b)(1) - Evacuation-Plan requires person in charge during emergency to designate an employee to call the fire dept in case of fire, explosion, toxic fumes
The evacuation plan policy did not address who will be designating an employee during an emergency. |
Yes |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
During the review of one staff file, it was observed that staff annual Truama training has expired. Staff took training last on 7-3-23. Staff took training immediately as such citation was corrected at inspection and copy of the training certificate taken. |
Yes |
| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
During todays walkthrough at the East building kitchen, one pack of bread was found to be open as the wrap was not sealed. TA was issued to the operation for this same standard during the last HM inspection on 2-22-24. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
2 residents physically assaulted one resident at the facility which resulted to the victim child sustaining concussion and head fracture. |
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| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
There was an inconsistency between the annual AWOL log and incident report regarding a resident AWOL. |
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| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
The child's service plan required a Safety Plan to be implemented to address his aggressive behaviors, particularly his pattern of targeting younger peers. The Safety plan was not created as documented. His supervision plan also mandated 1:1 supervision whenever the youth exhibited verbal or physical aggression. Residents and staff reported multiple incidents where the child hit or called younger peers names without provocation. Despite these behaviors, staff only intervened by separating the youth from peers or removing youth from the situation. However, 1:1 supervision was not implemented as required by the service plan following these incidents. |
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| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
During the review of one childs file today, it was noted that the invite to DFPS caseworker for the initial service plan meeting was not sent timely. Initial service plan was completed on 6-2-24 while the invite was sent on 6-3-24 a day after the plan meeting was completed. |
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| 4 | — |
748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model
One of five child records reviewed was found to be missing the medication administration record from a medication administered the night of the 12/28/23. |
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| 3 | — |
748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.
During the review of SIR reports, it was observed that the operation called in several serious incident reports involving unauthorize absences of children later than 6 hours from when the absence was discovered according to the time incidents were received by statewide intake in class. Incidents occured on 10-28-23 in investigation #3039668, on 11-3-23 in investigation #3041001 and on 11-5-23 in investigation #3041113 |
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| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
CCI Investigator observed staff sleeping at the facility while on duty and supervising children in care. Administrator was notified of the incident. |
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181 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.