Capacity 52. 0-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Medication records were found to to be incomplete. The medication record did not indicate the reason for the prescription. |
Yes |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
Kiddie Cottage one of the rooms missing a piece of siding and had protruding nail head. Outlet cover missing in the same room. |
— |
| 4 | — |
748.3443(a)(3) - Food Preparation-Food items must be protected from contamination
The kitchen area had several food products opened, not labled and expired in the refrigerator and /or freezer, food items were also observed on the floor. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
Video surveillance shows staff pushing a child. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
Child was not displaying any behaviors that warranted any emergency behavior intervention. |
— |
| 5 | — |
748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
A caregiver did not use the minimal amount of force when they utilized an inappropriate restraint technique, resulting in the child being thrown to the ground |
— |
| 4 | — |
748.3563(d) - Protective Surfacing-Must ensure 9 inches of the loose-fill materials are maintained at all times
There were areas at the playgrounds where loose-fill materials was not kept at a safe level where children in care may have a safety risk. |
— |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
Evacuation Plans at exits in the kitchen area do not provide a designated area to meet outside the operation. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
Child's Service Plan was not completed within 72 hours of admission and did not address supervision needs. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One child was administered a PM medication in the AM. |
— |
| 1 | — |
748.4213(d) - Emergency Care Discharge Plan-the preliminary discharge plan and weekly reviews must be available for Licensing review
There was no record of preliminary discharge plan being reviewed and updated at least weekly. |
— |
| 5 | — |
748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance
A passenger van did not have a working seatbelt during transportation of children. The work ticket was not submitted in a timely manner where youth in care was not properly supervised by a caretaker as required. Ticket 121 was presented on 7/13/23 to be fixed. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
A caregiver implemented EBI when a child in care was in crisis and in response to the child being reluctant to walk down the hallway and into the living room area. |
— |
| 1 | — |
748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom
Sleeping quarters at the Intake building required for children to cross a hallway and living space area to have bathroom access. |
— |
| 4 | — |
748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective
Staff should use attempt de-escalation techniques before attempting EBI. Staff needs to demonstrate knowledge of approved EBI techniques. |
— |
| 4 | — |
748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers
A child in care expressed suicidal ideations and made a suicidal gesture, but the information was not passed on to incoming caregivers and/or documented and shared with the child's treatment team. The fidget toy the child wrapped around his neck was taken away by the caregiver, but the child still had another fidget toy the same as the one used to wrap around his neck in his possession. Therefore, incoming caregivers were not aware that the child was trying to use the toy to self-harm. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care was left unsupervised in a bedroom and climbed onto a shelf of cubbies and fell and hit the back of the head on a metal bedframe on the way down. As a result, the child sustained a laceration. |
— |
| 2 | — |
748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours
A caregiver's training certificate for suicide did not document the length of the training in hours. |
— |
| 4 | — |
748.1337(b)(1)(D)(vi) - Initial Service Plan-Include instructions to caregivers about behavior intervention techniques
Behavioral intervention techniques, behaviors, and behavioral needs/goals are not present within a child's service plan. |
— |
| 1 | — |
748.1339(c) - Initial Service Plan-Child & parent must be invited to meeting to develop service plan & discuss participation in childhood activities
Two Initial Service plans were reviewed. There is no indication that the children participated in the service plan meeting. The documents were missing signatures, where a child would sign. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
An active Employee who provided direct care to children had an inactive background check. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child inappropriately touched another child by grabbing them in the private area. The child's supervision level was line of sight and the staff member failed to provide adequate supervision to the child. |
— |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
Two Initial Service Plans were reviewed. The children's parents/legal guardians were not invited to participate in the children's service plan meeting. |
— |
| 3 | — |
748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.
The EBI quarterly report was not submitted to Licensing, 15 days after the end of the 4th quarter. The quarterly report for the 1st quarter was not submitted to licensing. |
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
A caregiver did not document EBI used for a child in care and did not do so within 24 hours. |
— |
| 4 | — |
748.507(2) - Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator
Staff failed to report concerns for physical abuse of a child in care by another staff. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
Dear Provider: During a review conducted on December 9, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium high weighted citation in a pattern/trend category on August 28, 2024. Specifically, the operation was cited for 748.2003(b)(3): AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders. The operation met compliance on 09/10/2024. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
2 of the 5 children in care whose medication logs were reviewed were given medication twice in one day when the medication is prescribed for once a day. 1 of the 5 childrenin care whose medication logs were reviewed had a medication given 10 hours after the previous medication was administered when the medication should be given every 12 hours. |
— |
| 4 | — |
748.4657(1)(A) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI
A staff member has not received her 6 month annual training for SAMA/ EBI. The staff chart also included a sticky note indicating the staff member was overdue. |
— |
| 3 | — |
748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.
Parent, managing conservator, was not notified within the required timeframes of restraint. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
According to the medication log, a child in care did not receive the second dose of medication at noon as prescribed. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A caregiver?s intervention in a child?s behavioral incident lacked competency and prudent judgement due to the caregiver?s aggressive approach that appeared to have further aggravated the child?s behaviors. |
— |
| 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 had inappropriate relationships with children in care. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One child in care was given a PM medication in the AM. |
— |
| 4 | — |
748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.
A suicide screening was not conducted after a child in care expressed suicidal ideations to a caregiver and made a suicidal gesture. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
The sleeping quarters for both the girls and boys were unkept and the bathroom area had dirty towels on the floor. A shower head in the the girls dorm area was leaking water and staff stated it had been like that for several days. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on [June 10, 2025], it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium high weighted citation in a pattern/trend category on April 28, 2025. Specifically, the operation was cited for 748.507(2): Employee general responsibilities-Staff failed to report concerns for physical abuse of a child in care by another staff. The operation met compliance on 05/06/2025. Select those that apply, delete the other(s): - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. |
— |
| 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
There was no EBI documentation for a personal restraint. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The freezer located in Flores Girl's dorm did not have a working thermometer. A replacement thermometer was replaced in the freezer during inspection. |
Yes |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
It is corroborated that staff yelled at a child in care. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
Child's Service Plan was not completed within 72 hours of admission and did not address supervision needs. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
The sleeping quarters for both the girls and boys were unkept and the bathroom area had dirty towels on the floor. A shower head in the the girls dorm area was leaking water and staff stated it had been like that for several days. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A caregiver?s intervention in a child?s behavioral incident lacked competency and prudent judgement due to the caregiver?s aggressive approach that appeared to have further aggravated the child?s behaviors. |
— |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
Two Initial Service Plans were reviewed. The children's parents/legal guardians were not invited to participate in the children's service plan meeting. |
— |
| 1 | — |
748.4213(d) - Emergency Care Discharge Plan-the preliminary discharge plan and weekly reviews must be available for Licensing review
There was no record of preliminary discharge plan being reviewed and updated at least weekly. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One child was administered a PM medication in the AM. |
— |
| 1 | — |
748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom
Sleeping quarters at the Intake building required for children to cross a hallway and living space area to have bathroom access. |
— |
| 4 | — |
748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers
A child in care expressed suicidal ideations and made a suicidal gesture, but the information was not passed on to incoming caregivers and/or documented and shared with the child's treatment team. The fidget toy the child wrapped around his neck was taken away by the caregiver, but the child still had another fidget toy the same as the one used to wrap around his neck in his possession. Therefore, incoming caregivers were not aware that the child was trying to use the toy to self-harm. |
— |
| 1 | — |
748.1339(c) - Initial Service Plan-Child & parent must be invited to meeting to develop service plan & discuss participation in childhood activities
Two Initial Service plans were reviewed. There is no indication that the children participated in the service plan meeting. The documents were missing signatures, where a child would sign. |
— |
| 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 caregiver did not document EBI used for a child in care and did not do so within 24 hours. |
— |
| 4 | — |
748.3563(d) - Protective Surfacing-Must ensure 9 inches of the loose-fill materials are maintained at all times
There were areas at the playgrounds where loose-fill materials was not kept at a safe level where children in care may have a safety risk. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
Kiddie Cottage one of the rooms missing a piece of siding and had protruding nail head. Outlet cover missing in the same room. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Medication records were found to to be incomplete. The medication record did not indicate the reason for the prescription. |
Yes |
| 4 | — |
748.4657(1)(A) - Annual Training-Every 6 months a caregiver must complete at least 4 hours of training in EBI
A staff member has not received her 6 month annual training for SAMA/ EBI. The staff chart also included a sticky note indicating the staff member was overdue. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The freezer located in Flores Girl's dorm did not have a working thermometer. A replacement thermometer was replaced in the freezer during inspection. |
Yes |
| 4 | — |
748.507(2) - Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator
Staff failed to report concerns for physical abuse of a child in care by another staff. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
Video surveillance shows staff pushing a child. |
— |
| 4 | — |
748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.
A suicide screening was not conducted after a child in care expressed suicidal ideations to a caregiver and made a suicidal gesture. |
— |
| 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 had inappropriate relationships with children in care. |
— |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
Evacuation Plans at exits in the kitchen area do not provide a designated area to meet outside the operation. |
— |
| 4 | — |
748.1337(b)(1)(D)(vi) - Initial Service Plan-Include instructions to caregivers about behavior intervention techniques
Behavioral intervention techniques, behaviors, and behavioral needs/goals are not present within a child's service plan. |
— |
| 4 | — |
748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective
Staff should use attempt de-escalation techniques before attempting EBI. Staff needs to demonstrate knowledge of approved EBI techniques. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on [June 10, 2025], it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium high weighted citation in a pattern/trend category on April 28, 2025. Specifically, the operation was cited for 748.507(2): Employee general responsibilities-Staff failed to report concerns for physical abuse of a child in care by another staff. The operation met compliance on 05/06/2025. Select those that apply, delete the other(s): - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One child in care was given a PM medication in the AM. |
— |
| 5 | — |
748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
A caregiver did not use the minimal amount of force when they utilized an inappropriate restraint technique, resulting in the child being thrown to the ground |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care was left unsupervised in a bedroom and climbed onto a shelf of cubbies and fell and hit the back of the head on a metal bedframe on the way down. As a result, the child sustained a laceration. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
It is corroborated that staff yelled at a child in care. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
According to the medication log, a child in care did not receive the second dose of medication at noon as prescribed. |
— |
| 5 | — |
748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance
A passenger van did not have a working seatbelt during transportation of children. The work ticket was not submitted in a timely manner where youth in care was not properly supervised by a caretaker as required. Ticket 121 was presented on 7/13/23 to be fixed. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child inappropriately touched another child by grabbing them in the private area. The child's supervision level was line of sight and the staff member failed to provide adequate supervision to the child. |
— |
| 3 | — |
748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.
The EBI quarterly report was not submitted to Licensing, 15 days after the end of the 4th quarter. The quarterly report for the 1st quarter was not submitted to licensing. |
Yes |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
An active Employee who provided direct care to children had an inactive background check. |
— |
| 2 | — |
748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours
A caregiver's training certificate for suicide did not document the length of the training in hours. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
Dear Provider: During a review conducted on December 9, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium high weighted citation in a pattern/trend category on August 28, 2024. Specifically, the operation was cited for 748.2003(b)(3): AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders. The operation met compliance on 09/10/2024. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 3 | — |
748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.
Parent, managing conservator, was not notified within the required timeframes of restraint. |
— |
| 4 | — |
748.3443(a)(3) - Food Preparation-Food items must be protected from contamination
The kitchen area had several food products opened, not labled and expired in the refrigerator and /or freezer, food items were also observed on the floor. |
— |
| 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
There was no EBI documentation for a personal restraint. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
2 of the 5 children in care whose medication logs were reviewed were given medication twice in one day when the medication is prescribed for once a day. 1 of the 5 childrenin care whose medication logs were reviewed had a medication given 10 hours after the previous medication was administered when the medication should be given every 12 hours. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
Child was not displaying any behaviors that warranted any emergency behavior intervention. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
A caregiver implemented EBI when a child in care was in crisis and in response to the child being reluctant to walk down the hallway and into the living room area. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
Child was not displaying any behaviors that warranted any emergency behavior intervention. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Medication records were found to to be incomplete. The medication record did not indicate the reason for the prescription. |
Yes |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
A caregiver implemented EBI when a child in care was in crisis and in response to the child being reluctant to walk down the hallway and into the living room area. |
— |
| 4 | — |
748.1337(b)(1)(D)(vi) - Initial Service Plan-Include instructions to caregivers about behavior intervention techniques
Behavioral intervention techniques, behaviors, and behavioral needs/goals are not present within a child's service plan. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child inappropriately touched another child by grabbing them in the private area. The child's supervision level was line of sight and the staff member failed to provide adequate supervision to the child. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
An active Employee who provided direct care to children had an inactive background check. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
Child's Service Plan was not completed within 72 hours of admission and did not address supervision needs. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A caregiver?s intervention in a child?s behavioral incident lacked competency and prudent judgement due to the caregiver?s aggressive approach that appeared to have further aggravated the child?s behaviors. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
The sleeping quarters for both the girls and boys were unkept and the bathroom area had dirty towels on the floor. A shower head in the the girls dorm area was leaking water and staff stated it had been like that for several days. |
— |
| 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 had inappropriate relationships with children in care. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The freezer located in Flores Girl's dorm did not have a working thermometer. A replacement thermometer was replaced in the freezer during inspection. |
Yes |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
It is corroborated that staff yelled at a child in care. |
— |
| 3 | — |
748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.
The EBI quarterly report was not submitted to Licensing, 15 days after the end of the 4th quarter. The quarterly report for the 1st quarter was not submitted to licensing. |
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 [June 10, 2025], it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium high weighted citation in a pattern/trend category on April 28, 2025. Specifically, the operation was cited for 748.507(2): Employee general responsibilities-Staff failed to report concerns for physical abuse of a child in care by another staff. The operation met compliance on 05/06/2025. Select those that apply, delete the other(s): - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. |
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748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours
A caregiver's training certificate for suicide did not document the length of the training in hours. |
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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
There was no EBI documentation for a personal restraint. |
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| 1 | — |
748.1339(c) - Initial Service Plan-Child & parent must be invited to meeting to develop service plan & discuss participation in childhood activities
Two Initial Service plans were reviewed. There is no indication that the children participated in the service plan meeting. The documents were missing signatures, where a child would sign. |
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748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers
A child in care expressed suicidal ideations and made a suicidal gesture, but the information was not passed on to incoming caregivers and/or documented and shared with the child's treatment team. The fidget toy the child wrapped around his neck was taken away by the caregiver, but the child still had another fidget toy the same as the one used to wrap around his neck in his possession. Therefore, incoming caregivers were not aware that the child was trying to use the toy to self-harm. |
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748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.
A suicide screening was not conducted after a child in care expressed suicidal ideations to a caregiver and made a suicidal gesture. |
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| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
According to the medication log, a child in care did not receive the second dose of medication at noon as prescribed. |
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180 inspection record(s) on file from TX-HHSC.