Capacity 12. 7-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
During an investigation medical records requested, had incomplete logs of the residents refusing or taking medicine. |
— |
| 2 | — |
748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered
During the inspection of the vehicle the registration sticker for the vehicle was expired as of 12/25. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Nearly all documents provided were observed to be incomplete and/or partially provided and an incident report was unable to be located. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff members engaged in a verbal altercation in the presence of children in care. |
— |
| 4 | — |
748.535(3)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation
Interviews confirmed staff did not follow the safety plan implemented on a staff member. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During an investigation it was discovered that a resident in care was absent from the facility without the knowledge of staff for over an hour. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
Staff member put children at risk of harm by allowing the children to intervene when attempting to de-escalate an incident and in an emergency situation. |
— |
| 3 | — |
748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved
Serious incident report is documented as N/A where the information should include information for each child involved in the incident. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
During the inspection in bedroom 3 it was observed that there were no blinds or curtains. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During the inspection it was observed that in bedroom three, the window was broken. In place of the glass there is a plexy glass glued to the barrier of the window pane, and is not completely glued on. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
There is a cracked tile on the bottom floor and the flooring on the top floor is not well-maintained. Additionally, the return air vent has a build up of dust on the grate. There is mold/mildew in the upstairs bathroom. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk through there were 4 child beds missing mattress covers. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The annual summary log was observed to be missing all of the required criteria and only outlined the child's name, date of abscense, return date & hotline report confirmation number. |
— |
| 4 | — |
748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds
Expired medication dated 11/24/2024 was still in the medication bin on 12/03/2024. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
An employee, who is no longer employed at the operation, as of 11/23/2024, still have an active background check. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
Cleaning supplies were observed unlocked and accessible to children. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
Medication logs do not include the name and signature of the staff member who administered the medication. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
| 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.
A child in care was not administered a suicide risk screening on the date of admission. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Two medication logs were observed to be blank for the reason for the prescribed medication. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Although findings were inconclusive regarding a staff's inappropriate contact with a child, there is evidence to support a staff member had a lack of prudent judgment as a child was able to access a staff person's nude photo and save to their personal phone. Additionally, the staff member did not demonstrate competency to perform the job duties as a staffing plan was enforced by the operation to separate that same child from the staff member. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
Seven of seven medication log do not include the name and signature of the staff member who administered the medication. Only one medication log has a staff name, signature, and initial but the initial doesn't belong to any of the staff initials on the dates the medications were administered. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
None of the medication logs include the reason the medication was prescribed. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
During the inspection it was observed that the emergency evacuation diagram postings do not have anything to indicate where the children and staff should shelter in place during threatening weather. |
— |
| 5 | — |
745.8411(a) - Responsibilities - Not interfere with an inspection or investigation
Interviews confirmed staff interfering with investigation by asking other staff members to remove any evidence off their phones. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
None of the medication logs include the reason the medication was prescribed. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
Medication logs do not include the name and signature of the staff member who administered the medication. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff members engaged in a verbal altercation in the presence of children in care. |
— |
| 4 | — |
748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds
Expired medication dated 11/24/2024 was still in the medication bin on 12/03/2024. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
Cleaning supplies were observed unlocked and accessible to children. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The annual summary log was observed to be missing all of the required criteria and only outlined the child's name, date of abscense, return date & hotline report confirmation number. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Although findings were inconclusive regarding a staff's inappropriate contact with a child, there is evidence to support a staff member had a lack of prudent judgment as a child was able to access a staff person's nude photo and save to their personal phone. Additionally, the staff member did not demonstrate competency to perform the job duties as a staffing plan was enforced by the operation to separate that same child from the staff member. |
— |
| 2 | — |
748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered
During the inspection of the vehicle the registration sticker for the vehicle was expired as of 12/25. |
— |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
During the inspection it was observed that the emergency evacuation diagram postings do not have anything to indicate where the children and staff should shelter in place during threatening weather. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
During an investigation medical records requested, had incomplete logs of the residents refusing or taking medicine. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During the inspection it was observed that in bedroom three, the window was broken. In place of the glass there is a plexy glass glued to the barrier of the window pane, and is not completely glued on. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
An employee, who is no longer employed at the operation, as of 11/23/2024, still have an active background check. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
There is a cracked tile on the bottom floor and the flooring on the top floor is not well-maintained. Additionally, the return air vent has a build up of dust on the grate. There is mold/mildew in the upstairs bathroom. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
Staff member put children at risk of harm by allowing the children to intervene when attempting to de-escalate an incident and in an emergency situation. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During an investigation it was discovered that a resident in care was absent from the facility without the knowledge of staff for over an hour. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
Seven of seven medication log do not include the name and signature of the staff member who administered the medication. Only one medication log has a staff name, signature, and initial but the initial doesn't belong to any of the staff initials on the dates the medications were administered. |
— |
| 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.
A child in care was not administered a suicide risk screening on the date of admission. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Two medication logs were observed to be blank for the reason for the prescribed medication. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
During the inspection in bedroom 3 it was observed that there were no blinds or curtains. |
— |
| 4 | — |
748.535(3)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation
Interviews confirmed staff did not follow the safety plan implemented on a staff member. |
— |
| 5 | — |
745.8411(a) - Responsibilities - Not interfere with an inspection or investigation
Interviews confirmed staff interfering with investigation by asking other staff members to remove any evidence off their phones. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk through there were 4 child beds missing mattress covers. |
— |
| 3 | — |
748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved
Serious incident report is documented as N/A where the information should include information for each child involved in the incident. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Nearly all documents provided were observed to be incomplete and/or partially provided and an incident report was unable to be located. |
— |
| 3 | — |
748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved
Serious incident report is documented as N/A where the information should include information for each child involved in the incident. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
During the inspection in bedroom 3 it was observed that there were no blinds or curtains. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During the inspection it was observed that in bedroom three, the window was broken. In place of the glass there is a plexy glass glued to the barrier of the window pane, and is not completely glued on. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
Medication logs do not include the name and signature of the staff member who administered the medication. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Although findings were inconclusive regarding a staff's inappropriate contact with a child, there is evidence to support a staff member had a lack of prudent judgment as a child was able to access a staff person's nude photo and save to their personal phone. Additionally, the staff member did not demonstrate competency to perform the job duties as a staffing plan was enforced by the operation to separate that same child from the staff member. |
— |
| 2 | — |
748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered
During the inspection of the vehicle the registration sticker for the vehicle was expired as of 12/25. |
— |
| 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.
A child in care was not administered a suicide risk screening on the date of admission. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During an investigation it was discovered that a resident in care was absent from the facility without the knowledge of staff for over an hour. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
During an investigation medical records requested, had incomplete logs of the residents refusing or taking medicine. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The annual summary log was observed to be missing all of the required criteria and only outlined the child's name, date of abscense, return date & hotline report confirmation number. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
An employee, who is no longer employed at the operation, as of 11/23/2024, still have an active background check. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
None of the medication logs include the reason the medication was prescribed. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
Staff member put children at risk of harm by allowing the children to intervene when attempting to de-escalate an incident and in an emergency situation. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Nearly all documents provided were observed to be incomplete and/or partially provided and an incident report was unable to be located. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff members engaged in a verbal altercation in the presence of children in care. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
Seven of seven medication log do not include the name and signature of the staff member who administered the medication. Only one medication log has a staff name, signature, and initial but the initial doesn't belong to any of the staff initials on the dates the medications were administered. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
There is a cracked tile on the bottom floor and the flooring on the top floor is not well-maintained. Additionally, the return air vent has a build up of dust on the grate. There is mold/mildew in the upstairs bathroom. |
— |
| 5 | — |
745.8411(a) - Responsibilities - Not interfere with an inspection or investigation
Interviews confirmed staff interfering with investigation by asking other staff members to remove any evidence off their phones. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Two medication logs were observed to be blank for the reason for the prescribed medication. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
Cleaning supplies were observed unlocked and accessible to children. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk through there were 4 child beds missing mattress covers. |
— |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
During the inspection it was observed that the emergency evacuation diagram postings do not have anything to indicate where the children and staff should shelter in place during threatening weather. |
— |
| 4 | — |
748.535(3)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation
Interviews confirmed staff did not follow the safety plan implemented on a staff member. |
— |
| 4 | — |
748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds
Expired medication dated 11/24/2024 was still in the medication bin on 12/03/2024. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
None of the medication logs include the reason the medication was prescribed. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk through there were 4 child beds missing mattress covers. |
— |
| 5 | — |
745.8411(a) - Responsibilities - Not interfere with an inspection or investigation
Interviews confirmed staff interfering with investigation by asking other staff members to remove any evidence off their phones. |
— |
| 3 | — |
748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved
Serious incident report is documented as N/A where the information should include information for each child involved in the incident. |
— |
| 4 | — |
748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds
Expired medication dated 11/24/2024 was still in the medication bin on 12/03/2024. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
During the inspection in bedroom 3 it was observed that there were no blinds or curtains. |
— |
| 4 | — |
748.535(3)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation
Interviews confirmed staff did not follow the safety plan implemented on a staff member. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
Medication logs do not include the name and signature of the staff member who administered the medication. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The annual summary log was observed to be missing all of the required criteria and only outlined the child's name, date of abscense, return date & hotline report confirmation number. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
Staff member put children at risk of harm by allowing the children to intervene when attempting to de-escalate an incident and in an emergency situation. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During an investigation it was discovered that a resident in care was absent from the facility without the knowledge of staff for over an hour. |
— |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
During the inspection it was observed that the emergency evacuation diagram postings do not have anything to indicate where the children and staff should shelter in place during threatening weather. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Although findings were inconclusive regarding a staff's inappropriate contact with a child, there is evidence to support a staff member had a lack of prudent judgment as a child was able to access a staff person's nude photo and save to their personal phone. Additionally, the staff member did not demonstrate competency to perform the job duties as a staffing plan was enforced by the operation to separate that same child from the staff member. |
— |
| 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.
A child in care was not administered a suicide risk screening on the date of admission. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During the inspection it was observed that in bedroom three, the window was broken. In place of the glass there is a plexy glass glued to the barrier of the window pane, and is not completely glued on. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff members engaged in a verbal altercation in the presence of children in care. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
Seven of seven medication log do not include the name and signature of the staff member who administered the medication. Only one medication log has a staff name, signature, and initial but the initial doesn't belong to any of the staff initials on the dates the medications were administered. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
During an investigation medical records requested, had incomplete logs of the residents refusing or taking medicine. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Two medication logs were observed to be blank for the reason for the prescribed medication. |
— |
| 2 | — |
748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered
During the inspection of the vehicle the registration sticker for the vehicle was expired as of 12/25. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Nearly all documents provided were observed to be incomplete and/or partially provided and an incident report was unable to be located. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
Cleaning supplies were observed unlocked and accessible to children. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
An employee, who is no longer employed at the operation, as of 11/23/2024, still have an active background check. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
There is a cracked tile on the bottom floor and the flooring on the top floor is not well-maintained. Additionally, the return air vent has a build up of dust on the grate. There is mold/mildew in the upstairs bathroom. |
— |
| 4 | — |
748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds
Expired medication dated 11/24/2024 was still in the medication bin on 12/03/2024. |
— |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
During the inspection it was observed that the emergency evacuation diagram postings do not have anything to indicate where the children and staff should shelter in place during threatening weather. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
Staff member put children at risk of harm by allowing the children to intervene when attempting to de-escalate an incident and in an emergency situation. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
None of the medication logs include the reason the medication was prescribed. Operation was previously found deficient and technical assistance was provided. Operation is not following the compliance plan submitted to Licensing because the operation is still non-compliant regarding the medication logs. |
— |
72 inspection record(s) on file from TX-HHSC.