Capacity 50. 7-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.2009(a)(2) - Inform child's prescribing health-care professional of administration/dosage of any non-prescription medications or supplements
During the investigation, it was made known that a staff member administered an over-the-counter medicine to a child in care who had an allergy to the medication. |
— |
| 4 | — |
748.3441(r) - Food Preparation-Uneaten food from a person's plate must not be served again or used in the preparation of other dishes
During an inspection of the cottage refrigerators, it was discovered that 2 residents had saved their leftovers on their plate and placed them in the refrigerator to continue to eat at a later time. Both plates were also uncovered. |
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| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It was found that one staff with direct access to children in care has a provisional status pending an out-of-state background check as of 9/15/23 and the operation has not been following the conditions set by CBCU for this individual until the operation was informed by licensing on 12/15/23. This staff has been left alone with children in care as an awake night staff and has administered medications to children in care between these dates above. |
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| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
During the investigation, it was made known that a staff member did not follow the operations policies when administering medications. |
— |
| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
A caregiver was left with six children to supervise while the second caregiver took two children to the store. |
— |
| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
It was found during the investigation that periodically during an all for support call or a perimeter search, staff are left out of ratio for periods of time in both the RTC and GH cottages. |
— |
| 4 | — |
748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required
The supervision requirements listed in the child's Service plan were confusing and contradictory not giving staff clear and understandable direction in meeting the child's needs. |
— |
| 3 | — |
748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.
One of the ten Serious Incident Reports read were not reported to the Intake Line as required when police responded to the facility. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
During the inspection, the medication cart was not locked at the Moody Cottage staff office. |
Yes |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Through interviews with staff and reviewing documentation, it was determined that signatures on medications logs were forged, and a therapy note contained inaccurate information. |
— |
| 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
In one of the two EBI Serious Incident Reports provided by the operation, the operation did not have a completed document with all required information. The report did not include the date and time the intervention was administered, did not provide any de-escalation techniques used, amount of time spent de-escalating with the youth, and did not include the date and time offered the discussion nor the child?s reaction to the opportunity for discussion. A completed document was subsequently completed and provided by the operation to RCCR over sixty days after the initiation of the EBI intervention. |
— |
| 5 | — |
748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously
It was determined a child in care was denied a request to contact the Texas Abuse Hotline. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
Due to a window being faulty, a child was able to open it and enter into staff office. The child was then able to access a kitchen knife and self-harm. |
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| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
During the investigation, it was determined that staff failed to follow agency policy requiring hygiene items, especially those containing sharp objects, to be inventoried in the office before being distributed to children. The hygiene items were inventoried in the dorm living area, and staff did not identify that a nail kit was included in the items. The nail kit was later used by a child for self-harm, creating a safety risk. |
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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
A child in care self-harmed and was on a safety plan when the child in care self-harmed the next day using sharp items which were not allowed to be used unsupervised per the safety plan the day before. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
During an investigation that medication errors are not being documented within 24 hours but on a weekly basis and may not be being filled out by the person finding the error. |
— |
| 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 in care was prescribed an inhaler for asthma that was to be used every 4 hours as needed. While participating in a higher risk water activity, the child began to have trouble breathing and wanted this inhaler. Caregivers had not brought the inhaler on the outing and therefore the child was not able to use their medication as prescribed. The child had a fainting episode and was taken to the emergency room. |
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| 4 | — |
748.3441(n) - Food Preparation-Food must be protected from contamination
During the inspection, I observed food containers not properly stored and food not properly covered or put away. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
It was identified 17 medication incident reports, used to document medication errors, were not documented within 24 hours. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff did not act prudently when storing a medication in a cup that a resident in care did not take. As a result, the medication could not be located by staff the following morning. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
During an inspection of the RTC cottages it was observed that the couches in the living areas are torn in several places and have holes in them. Trash and other items are being stuffed into these holes. |
— |
| 4 | — |
748.2101(7) - Medication storage & destruction-remove medication on/before the expiration date & destroy it in a way that ensures children do not have access
It was identified during the course of this investigation that expired medication was administered to a child in care. This medication was known by the operation to have been expired prior to the administration, continued to be accessible, and was administered to a child during a suspected medical event. |
— |
| 4 | — |
748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container
One out of two cottages observed, contained Schedule II medications that were not double locked as required. The office door was locked; however, the cart inside the office containing Schedule II medications was not locked and there were no staff observed in the area administering medication at that time. This was corrected at the inspection when operation staff locked the medication cart. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff did not use prudent judgement when allowing the children to play a game that entailed throwing eggs at one another and would have prevented an altercation from occurring. |
— |
| 4 | — |
748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child
The serious incident reports that the incidents occurred on 1/25/2026, 4:30 PM. The incident was taken by intake on 1/27/2026 at 4:53 PM. The incident was not reported timely to licensing. There is a violation of this standard for reporting to licensing. |
— |
| 3 | — |
748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period
One out of three staff files reviewed did not have current annual training in Normalcy, TIC, Psychotropic medication, and Reporting abuse and neglect. |
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 identified that 2 medication rercords for 2 children in care lacked the signature of the person who administered the medication and the number of medication dispensed to each child. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
The medication log and medical incident report showed that a child in care received 2 doses of a medication instead of 1 as prescribed. |
— |
| 4 | — |
748.2307(4) - Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse
The investigation concluded that a staff used condescending and sarcastic comments towards 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
It was Identified tha a child in care was prescribed medication on 05/27/2022 and this medication, as of 6/24/2022 has not been administered to the child. |
— |
| 2 | — |
748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting
Through interviews and documentation, it was determined that children in care were not receiving therapy as required by their service plan therapeutic needs and goals. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
It was determined on 3/17/26 and on 3/18/26 a child that was on a Safety Plan and not allowed outside alone was able to get past staff who were performing duties that interfered with their supervision and the child was able to self-harm. Supervising staff stated they were performing other duties that hindered supervision. |
— |
| 4 | — |
748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
Three children touched one another inappropriately in the back seat of the facility van. Records note all three children have a history of poor boundaries that require close supervision. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
A direct care worker has been working at the operation with an inactive background check since June 2021. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
The refrigerator located in CASA SARA had opened food items that were not stored in proper storage containers. |
— |
| 4 | — |
748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
A child in care, who had previously exhibited self harm behaviors, was left alone in a cottage with a Mental Health Officer (MHO). When leaving the cottage, a staff member failed to lock the top portion of the office door, where scissors were on the staff desk, and did not notify the MHO of the safety hazard. The child was able to gain access to the scissors and attempted to self harm once again. |
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| 4 | — |
748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work
It was determined a staff member prepared and administered medication during a one-hour time frame while being responsible in caring for children. |
— |
| 3 | — |
748.2151(e) - Medication Record-must document non-prescription medication or supplement given to child and how often given
It was identified that 2 medication rercords for 2 children in care lacked the signature of the person who administered the medication and the number of medication dispensed to each child. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During a walkthrough of the operation's main kitchen and the cottage kitchens, it was found that several food items were past their expiration date. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
In an investigation conducted by DFPS, one staff was confirmed to have medically neglected and neglectfully supervised a child in care. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
Two out of two cottages walked through were observed with unsealed or uncovered food items in the refrigerator or freezer. This was corrected at the inspection when staff conducting the walk through either covered the item or discarded it. |
Yes |
| 4 | — |
748.685(b)(5) - Caregiver responsibility - when deciding how close to supervise, takes into account the child's physical, mental, emotional, and social needs
It was found that a staff left the children in the RTC alone on an outing at a McDonald's for approx. a couple to a few minutes. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
A child in care was able to find a piece of glass outside and swallow it. Other collateral children confirm that it is common to see hazards such as glass outside. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
During the course of the investigation it was found that the window alarm went off and was heard, but no one checked to ensure that it was not from the staff entering and leaving the building. Furthermore it was determined supervision was done primarily through the cameras knowing the victims were upset and had a history of running away. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
The safety plan dated 7.10.23 states the following: Staff will complete 15-minute visual checks to ensure the child is committing to safety and remaining safe. This safety plan did not expire until 7.14.23. On 7.13.23 the child was issued a 2 hour unsupervised, off campus walking pass . |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the course of this investigation, it was determined that a staff member used inappropriate language in the presence of children in care. |
— |
| 3 | — |
748.1337(b)(1)(D)(i) - Initial Service Plan-Include child's personal trauma history
A child's service plan did not include their personal trauma history and what led to CPS involvement and removal from their home of origin. |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
Medication was found in clear ziploc bags and not in the original container. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
The medication cart was left unlocked and a child in care was able to gain access, ingest, and self-harm with another child's medication. |
— |
| 4 | — |
748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container
The medication cart was left unlocked as well as the staff office door, leaving the Schedule II medications accessible to all the residents and not double locked as required. |
— |
| 4 | — |
748.1661(c) - Tobacco Products-Adult may only smoke tobacco products, e-cigarettes, or vaporizers on premises at a safe distance from child living area
The operation has allowed a staff member to smoke in an area that is not a safe distance from the children's living area. |
— |
| 4 | — |
748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
Three residents at the operation described seeing a staff member sleeping in the office on three separate occasions during the night hours. |
— |
| 4 | — |
748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person
During an investigation it was discovered a child in care was given another child in care's medication. |
— |
| 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
During the course of the investigation it was found a staff stopped working for the facility around Aug.4,2021, but was still showing as active on 8/15/21 and 8/26/21. |
— |
| 5 | — |
748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.
A child in care was restrained over the maximum length of time. The restraint was said by staff to have lasted at least 30 minutes up to 45 minutes and was documented in the serious incident report to have lasted 40 minutes. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
During an investigation, residents indicated that they were squirted with a water gun that had a garlic powder in it. This was used as an intent to have residents come inside and take showers by a staff member. |
— |
| 4 | — |
748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair
While conducting a walk through, the stove top and microwave were observed with stuck on food particles, the counter tops/food preparation area contained trash, the cabinet was hanging from its hinges, and the bottom of the freezer contained loose food that had fallen out of a package. |
— |
| 3 | — |
748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.
In one of the two Serious Incident Reports provided by the operation, the notification of the Emergency Behavior Intervention to the Caseworker was dated as occurring six days after the incident occurred. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child in distress left the cottage without permission. The caregiver remained on the cottage did not maintain any visual or auditory supervision of the child. |
— |
| 3 | — |
748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease
A child and staff member tested positive for a communicable disease one tested positive on 12/31/2021 the other on 1/1/2022. The positive results were not reported to Licensing until 1/3/2022 |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
On 7/18/2024 six residents were not provided their morning medications. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
A child's service plan has multiple instances of not documenting accurate information by either being blank, not completing the sentence, or using verbiage such as "is/ is not" or "has/ has not" but not selecting which phrase is most appropriate for that section being described. |
— |
| 3 | — |
748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.
The parent was notified via email about the restraint occurring within 72 hours, however, the following required information was not included in the required timeframe: -the EBI administered -the length of the restraint -the child's condition following the release of the restraint |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
A child was able to gain access to ibuprofen that was being stored in a safety bag |
— |
| 4 | — |
748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid
One employee who is counted in ratio, did not have first aid training. |
— |
| 4 | — |
748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
Five individuals interviewed acknowledged witnessing staff, who acknowledged being responsible for checking on the children, sleeping during their shift. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
On 10/31/25 a child in care was administered evening medication by a staff who only initialed the medication log, The staff's signature is not on the signature page showing which staff administered medication to that child for that month. |
— |
| 4 | — |
748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
Through interviews and documentation reviewed, staff were not following two active safety plans that state two specific residents are not allowed in the courtyard at the same time and to take one or the other inside immediately . |
— |
| 3 | — |
748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor
Durning the investigation, food boxes were stored on the floor of the walkin freezer. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
During a walkthrough of the operation several food items were being stored in the cottage refrigerators with no lid or cover. |
— |
| 3 | — |
748.705(b)(3) - Reasonable & prudent parent standard-must consider the child's behavioral history and ability to safely participate in proposed activity
The daily progress note dated 3 days prior to the incident stated the child had high risk suicidal and runaway ideations. The child?s behavioral history in days prior to the incident should have been taken into account. The child was also on a safety plan requiring 15-minute visual checks for having suicidal and runaway ideations 3 days prior. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection today, two fridges (white one and the small black one) at Casa Sara group home was observed without thermometers and one freezer was observed to be btw 15-20 degrees Farenheit. Additionally, on 5/10/24, the stainless steel fridge thermometer was observed to be over 40 degrees Farenheit and the other fridges didn't have thermometers either, these were at the same group home. |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Through interviews it was determined that staff are cursing when talking to other staff and children in care can hear it. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During the course of the investigation it was determined there was an issue with mold/mildew in the children's shower. |
Yes |
| 4 | — |
748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
After a serious incident, staff assessed a child required heightened supervision through stabilization. Staff did not implement the needed supervision as the child was allowed to go outside unsupervised for over 15 minutes. During this time, the child was able to elope from the operation. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly
Dish washing pods were observed in an unlocked cabinet in the kitchen at Moody cottage. Two out of three of the cottages that were walked through, did not show a return date for sharps that were checked out on a previous date in the month of August. |
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| 4 | — |
748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair
During the inspection, I observed there to be food and trash left on food preparation areas. There were piles of debris left on floor where it was swept but not picked up. Stovetop was not clean as rice debris was left on it. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
An overnight caregiver was noted to be sleeping during their shift. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child was able to get into the unlocked staff office, access and ingest medication from the unlocked medication cart and obtain a knife before staff was able to intervene. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Operational protocols were not being followed regarding staff documenting razors being checked out to residents and being checked back in. As a result, a child had access to a razor for unknown period of time and the child self-harmed with that razor. |
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| 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
It was reported and confirmed that a staff member used and held their cell phone while transporting children in care. It was also reported that the staff member had used their Air Pods to listen to a Podcast or YouTube Premium while driving children in care. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
Staff administered a restraint in a non-emergency situation in order to obtain a THC and nicotine vape from a youth in care. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
It was reported a staff member cursed in the presence of a child in care. It was confirmed that a staff member cursed both at a child in care and in their presence. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
During an investigation, it was found multiple medications were not being given as prescribed. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During the course of the investigation, it was found that a staff administered a prescription medication for mood stabilization excessively to a child in care from Nov. 6 - Nov. 7, 2023 and did not follow the doctor's signed orders for this medication, the medication log, and/or the prescription instruction label. This medication was ordered to be administered by mouth twice daily. During the above-mentioned timeframe, staff administered this prescription medication twice in the morning (two 600 mg tablets) and once at night (one 600 mg tablet). Additionally, from 11/6/23 to 11/9/23, 11/14/23, and 11/16/23 this child's medications were administered by a staff person who was not supposed to administer meds to children in care due to a BCG condition. The operation was also cited for this same standard twice in 2022. |
— |
| 4 | — |
748.1101(b)(1)(A) - Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible
It was identified during this investigation that a male staff member entered a bathroom while a female child in care was showering. |
— |
| 3 | — |
748.2855(a)(10) - EBI Documentation-Must include all attempts to explain to the child what behaviors were necessary for release from the intervention.
The EBI report for 8.22.23 did not document any attempts the staff made to explain to the child what behaviors were necessary for release from the restraint. |
— |
| 4 | — |
748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
Through interviews and documentation reviewed, staff were not following two active safety plans that state two specific residents are not allowed in the courtyard at the same time and to take one or the other inside immediately . |
— |
| 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
During the course of the investigation it was found a staff stopped working for the facility around Aug.4,2021, but was still showing as active on 8/15/21 and 8/26/21. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child in distress left the cottage without permission. The caregiver remained on the cottage did not maintain any visual or auditory supervision of the child. |
— |
| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
It was found during the investigation that periodically during an all for support call or a perimeter search, staff are left out of ratio for periods of time in both the RTC and GH cottages. |
— |
| 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 Identified tha a child in care was prescribed medication on 05/27/2022 and this medication, as of 6/24/2022 has not been administered to the child. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
A child was able to gain access to ibuprofen that was being stored in a safety bag |
— |
| 4 | — |
748.3441(n) - Food Preparation-Food must be protected from contamination
During the inspection, I observed food containers not properly stored and food not properly covered or put away. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
Staff administered a restraint in a non-emergency situation in order to obtain a THC and nicotine vape from a youth in care. |
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| 4 | — |
748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid
One employee who is counted in ratio, did not have first aid training. |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the course of this investigation, it was determined that a staff member used inappropriate language in the presence of children in care. |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Through interviews it was determined that staff are cursing when talking to other staff and children in care can hear it. |
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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
An overnight caregiver was noted to be sleeping during their shift. |
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| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
During the course of the investigation it was found that the window alarm went off and was heard, but no one checked to ensure that it was not from the staff entering and leaving the building. Furthermore it was determined supervision was done primarily through the cameras knowing the victims were upset and had a history of running away. |
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460 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.