summary: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

raw_content: 2 children interviewed mentioned a staff threatened at least 1 child with corporal punishment.


state: TX

facility_name: Texas NeuroRehab Center

summary: 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

raw_content: During an interviews staff stated that a child was escorted from the school building back to the Sierra Unit. This walk would take over 1 minute making it a personal restraint which is required to be documented.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative:
On 7.23.24 the operation emailed their action plan for the above deficiency.

The staff that were involved in the related EBI were individually re-educated on the requirement to document all interventions that meet the definition of an EBI.  The actual incident of the escort that lasted for more than one minute and restricted the movement of the patient was used as illustration.  This education was provided by the Director of Nursing on 7/23/24.

The Satori trainer was asked to include patient escort as an example of an EBI with new hires and recertifications.


summary: 748.949(a) - Annual Training Documentation-Keep documentation verifying completion of training in the personnel record

raw_content: The facility was unable to provide documentation to show which trainings the staff took with the required information.

Standard Risk Level: Medium Low

Correction Narrative: Received email from the facility that they will now be keeping their own paper charts for training.


summary: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force

raw_content: During a restraint, a staff used excessive force to take a child to the ground, causing the child to chip a tooth upon impact.

Standard Risk Level: High

Correction Narrative:
A discussion was had with the Administrator. There are 2 Satori Trainers- 1 is not at the operation and the other is currently teaching a class. Staff were unable to be interviewed as they are running  in ratio and 1 child is on a 1 to 1.
The "Education Topics" discussed within EBI training were reviewed. It discusses specifically minimizing movements, using less restrictive alternatives, and using the least amount of force necessary. Additionally, taking the patient seriously is discussed.


summary: 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

raw_content: During the inspection, it was observed two caregivers were left with fifteen children for approximately ten minutes.   This was corrected when the third caregiver returned to the unit.

Standard Risk Level: Medium High

Corrected at Inspection: Yes


summary: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

raw_content: A staff member has been working at the operation since 12.26.23 with an inactive background check.

Correction Narrative:
The staff involved was made active and eligible on 5.14.24.
An email was received from the operation on 5.15.24. It was explained the Human Resources Director has implemented an additional security check to ensure that active employees are not inadvertently de-activated by creating a spreadsheet for additional weekly review.


summary: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

raw_content: During interviews 3 out of 3 children stated staff use profane language around them. 2 staff memebers also admitted to using profane language.

Correction Narrative: During an in person follow up inspection, 6 resdients interviewed stated that they have not heard any staff members using profane language.


raw_content: During the course of the investigation, it was determined that the caregiver used more force causing injury to a child.

Standard Number / Description: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force

Correction Narrative:
Inspection #4003794
A conversation was had with the Chief Operating Officer. It was explained the Trauma Informed Care training would be completed with all staff by the end of June. There are 5 dates the training is being offered to allow all staff to attend.
No staff were interviewed as this training has not been completed yet.
No children were interviewed as this training does not pertain to them.

An email was received on 5.17.24 from the operation. The staff involved has been deactivated from the operation. The Leadership team met to address the citation and agreed reducing physical hold is an important initiative that will help prevent injury to the patients. All direct care staff will receive additional TIC that is enhanced over prior TIC. This will focus on avoiding power struggles and on aggression. The training will be presented by the Director of Clinical Services. All will be trained by 6.30.24.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: During the course of the investigation, it was determined that the caregiver used a type of restraint that was not allowed.

Correction Narrative:
Inspection #4003794

A conversation was had with the Chief Operating Officer. It was explained the Trauma Informed Care training would be completed with all staff by the end of June. There are 5 dates the training is being offered to allow all staff to attend.
No staff were interviewed as this training has not been completed yet.
No children were interviewed as this training does not pertain to them.

An email was received on 5.17.24 from the operation. The staff involved has been deactivated from the operation. The Leadership team met to address the citation and agreed reducing physical hold is an important initiative that will help prevent injury to the patients. All direct care staff will receive additional TIC that is enhanced over prior TIC. This will focus on avoiding power struggles and on aggression. The training will be presented by the Director of Clinical Services. All will be trained by 6.30.24.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: During the course of the investigation, it was determined that a child in care had their arm held behind their back during an emergency behavior intervention.


summary: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

raw_content: This standards was found deficient as part of a DFPS investigation.

Correction Narrative:
A conversation was had with the Cheif Operating Officer. It was explained the Trauma Informed Care training would be completed with all staff by the end of June. There are 5 dates the training is being offered to allow all staff to attend.
No staff were interviewed as this training has not been completed yet.
No children were interviewed as this training does not pertain to them.


summary: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

raw_content: The incident occurred on 1.23.24 and the child made the allegations the same day during the debriefing. However, the incident was not reported to Licensing until 2.29.24.

Correction Narrative:
A conversation was held with the Administrator face to face while at the operation. It was explained serious incident reporting would be retrained on during the Competency Fair that is being held mid June. The trainings are mandatory for each staff member.

No children were interviewed. No staff were interviewed as the trainings have not yet been offered.


raw_content: The incident took place on 12.17.24 but was not reported to licensing until 12.27.24.

Standard Number / Description: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

Correction Narrative: This standard was reviewed for compliance.


summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: During the investigation, it was determined that the operation failed to submit the serious incident report within the required timeframe.  The incident occurred on 12/22/23 and was reported to Licensing on 12/26/23.

Correction Narrative: The Central Nursing Supervisors, The Administrators on Call and the nursing staff received training related to the process of reporting serious incidents at Texas NeuroRehab Center.  The training  was developed by the Risk Manager.


raw_content: A child in care was hit and choked by a staff member. This incident meets Texas Family Code and Texas Administrative Code definition of abuse.

Standard Number / Description: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

Correction Narrative: 2 employees, DON and Adminsitrator, were interviewed regarding an abuse/neglect training being created that will be submitted to HR by no later than today.


summary: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

raw_content: Mold was observed in the Sierra unit showers.


summary: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

raw_content: It was discovered the child was administered the wrong medication accidently, one they were documented to be allergic to. The child did not have a reaction to the medication, so it was added to their daily medication regimen.

Correction Narrative: An email was received from the operation on 12.22.23. It was explained the Chief Nursing Officer and Medical Director have agreed that beginning 12.21.23 if a physician is prescribing any medication that is listed as an allergy for a patient, the physician will acknowledge the allergy with a brief justification on the order indicating they are aware of the allergy. This will make it clear the physician is making a clinical decision to prescribe the medication and the administration is not an error.


summary: 748.3115(2) - Fire Extinguisher-Must ensure fire extinguishers are accessible for immediate use by employees, caregivers, & volunteers

raw_content:
It was observed in the gym that there was no fire extinguisher found in the vicinity.

This was corrected during the inspection when the maintenance worker sent a picture to the administrator of the fire extinguisher being posted in the gym.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: It was observed in the gym that three window panels were missing/broken, It was also found that one of the closets in the gym was unlocked and a hole in the ceiling along with the light fixture was not turning on properly was observed.


summary: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: It was observed on the sidewalk outside of the gym there were animal feces in dog bags.


summary: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

raw_content: Two children in care spent several days creating a hole big enough to escape unnoticed. During the time the children in care eloped, caretakers conducted routine 15-minute checks and marked them in their rooms.

Correction Narrative:
The following steps were taken to address the supervision concerns:

The Rehab Tech on duty received education and a Corrective Action Report.
The Nurse on duty that oversees the Rehab Tech received an Education Topic Reinforcement.

The above steps were completed on 6/28/23 and 6/26/23 respectively.

Monitoring occurs via leadership rounding which occurs every week, on the weekend and the evening and overnight shifts.  The rounding sheets are reviewed by the Risk Manager for compliance.


summary: 748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.

raw_content: The incident was reported to the hotline sixteen hours after the children in care were noticed missing and not reported within six hours. During the course of the investigation, it was noticed that only one victim was reported missing when two children in care eloped from the facility.

Correction Narrative:
On call administrative staff reviewed the expectations of making timely reports to licensing.  Internal communication expectations were reviewed.
The above step was completed on 6/30/23.


summary: 748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions

raw_content: The facility failed to provide RCCL Inspectors with a serious incident report or formal facility report for the incident. Requests for an incident report were made on 06/15/2023, 06/28/2023, and 07/19/2023, requests were made in person and through email.

Correction Narrative: It is now clear that the investigator wanted the incident information on a form as opposed to the information being provided in a narrative format.  A narrative was provided on two occasions.  A form has been identified that should suffice in providing the information.  A form will be provided in future requests.  This form related to this incident was provided to licensing representative, Kaeli Yager, on 8/7/23 when she clarified that a form was required, not simply the information in narrative form.


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: It was determined that a nurse had multiple medications ready to disburse hours prior to the time the medication is labeled to be administered.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: It was found that three future time and signature were documented in a medication record prior to administering the medication. One medication record had the incorrect count documented. It was also found that one medication record was missing information on who disbursed the medication.


summary: 748.191(2) - Required Postings-Post Licensing notice Keeping Children Safe in prominent and publicly accessible place where others may easily view it at all times

raw_content: There was no Keeping Children Safe poster located anywhere in the Chaparral Unit.


summary: 748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor

raw_content: During the walk-through of the cafeteria, it was noted that pork was kept uncovered in the freezer, a stainless-steel container of peaches in juice were kept uncovered on a cart located in a hallway in the cafeteria and a bowl of food was uncovered in the refrigerator located in the cafeteria entrance.

Category: Physical Site


raw_content: 8 noted times on 6 medication records/logs did not document administered medication.

Standard Number / Description: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

Category: Medication


summary: 748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children

raw_content: It was reported that all showers in the Chaparral and Sierra Unit were not in working condition as of three week prior to this date. Children in care take turns every other day to take showers in another building not subject to regulation.


summary: 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

raw_content: There were two staff members 13 resident in the Sierra Unit. As per staff the nurse was counted in ration. There were 14 residents to 2 staff members in the Chaparral Unit. Both nurses were seen in the locked nurse s station administering medication.


summary: 748.2551(b)(1) - EBI Implementation-The caregiver must consider the characteristics of the immediate physical environment

raw_content: It was determined that a child was restrained by staff in a wooded area in an attempt to stop them from elopement. This area was reported to be an open field with extensive brush, trees, frontage including thorns. After multiple attempts to restrain the child, there were four reported physical altercations between staff and child in where they fell on to the described brush. As such, the staff sustained several injuries.

Correction Narrative:
As per Director of PI/Compliance, re-education of the staff involved in the physical hold cited will occur by 12/30/22.  Other current Nurses and Rehab Techs will be re-educated by 1/19/23. The new hire orientation will be reviewed and modified to emphasize the importance of considering the environment prior to implementing a physical hold.  Examples will be used and include outside hazards (such as rough terrain, uneven terrain, ant beds, trees, etc) as well as inside hazards (such as small spaces, furniture etc).
The Director of Nursing and/or the Nurse Educator will provide the training. The Director of Nursing will monitor compliance of training via HealthStream.
The Restraint and Seclusion Policy was reviewed and affirmed it meets regulatory requirements.
The Director of Nursing will review all Restraint forms for compliance.


summary: 748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective

raw_content: It was concluded that a staff member subjected a child to an unnecessary EBI as a means to comply.


summary: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child

raw_content: During the course of this investigation, it was determined that a staff member conducted an unnecessary EBI and used unnecessary strength forcing a child in care to the ground causing a bruise on their face. It was determined that the child was not a danger to self and/or others.


summary: 748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.

raw_content: Both Chaparral and Sierra Unit walls had extensive peeling.

Correction Narrative: The units are scheduled to be painted when the patients return to school in mid-August.


raw_content: During the course of this investigation, it was determined that a child in care was improperly restrained and not documented.

Standard Number / Description: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child

Correction Narrative: The staff involved was assigned and completed a Satori refresher course on 6/21/22. The staff was assigned training on Special Treatment Procedure documentation. This training will be completed no later than 6/30/22.


summary: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

raw_content: During a walk through of the operation, 9 large cans, an unopened box of ravioles and a plastic jar of liquid were observed to be expired in the Cafeteria's pantry area.

Correction Narrative:
748.3441(a): Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions.
The Food Service Manager labeled the shelves in the dry storage area (picture attached).  The Food Service Manager clarified that the top shelf is for emergency food items like tuna, ravioli, peanut butter and long shelf life foods. The lower shelf is for dented cans, damaged items and items that arrived with a limited time before expiration. These food products remain on this shelf until the food delivery representative comes and gives credit to the account.
The Food Service Manager will monitor the dry storage area weekly to assure that the labels stay in place.


summary: 748.931(a)(1)(B)(i) - Annual Training-Must include 2 hours on trauma informed care

raw_content: During the monitoring inspection, four staff files were reviewed. It was noted that four of the four staff files did not provide documentation regarding Normalcy training. 748.749(b)(5): One of the four staff files reviewed had training certificated that did not specify the training hours.

Category: Training and Professional Development

Correction Narrative:
748.931(a)(1)(B)(i) Annual Training-Must include 2 hours on trauma informed care
The Human Resources Trainer assigned all Ponderosa (Child and Adolescent Units) staff the courses available on the Texas HHSC website that relate to trauma informed care and normalcy.  This action was implemented immediately.  These two courses are assigned annually.  The Human Resources department tracks the completion of courses and notifies supervisors if employees do not complete required training.  The assignments were effective August 1, 2021.  Non-compliance of training is reported to the appropriate supervisor, the appropriate manager, CEO,COO, DON, Director of Clinical Services and Compliance Officer/PI Director.
The Human Resources Department will add hours of training to all training provided at the facility.  The Director or designee will audit files on an ongoing basis for compliance.  Omissions will be corrected immediately by the Human Resources trainer who will add the hours of training to documentation.


summary: 748.363(8) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: During the monitoring inspection, four staff files were reviewed. One staff file did not contain a signed and dated statement in where an employee must immediately report any suspected incident of child abuse, neglect, or exploitation to the Texas Abuse and Neglect Hot line and to the operation s administrator and/or administrator s. 748.831(b): The same staff file did not contain orientation documentation.

Category: Reports and Record Keeping

Correction Narrative:
748.363(8) Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.
The Human Resources Director has developed an attestation that reads:
I understand that I must immediately report any suspected incident of child abuse, neglect or exploitation to the Texas Abuse and Neglect Hotline and to TNC's administrator or administrator's designee (CNS).
New hires that work with the Child/Adolescent programs are now required to read and sign the attestation.  Current employees were provided the statement with the expectation that they sign and return the statement immediately.  This will be tracked electronically and monitored through Healthstream. Non-compliance of completion is reported to the appropriate supervisor, Manager, CEO, COO, DON, Director of Clinical Services and the Compliance Officer/PI Director.  All current employees were provided the new statement to sign and return to Human Resources.
Each new employee has an orientation checklist that is specific to their job description.  The supervisor of each employee is responsible for assuring that the orientation checklist is completed.  The completed checklist is forwarded to the Human Resources department who will monitor for completion.  Instances of noncompliance will be reported to the appropriate supervisor, Manager, CEO, COO, DON, Director of Clinical Services and the  Compliance Officer/PI Director.


raw_content: During a follow up inspection, one frozen food item and several refridgerated condensed dairy cartons were observed to be expired in the Cafeteria and the same condensed dairy cartons observed also had mold on the outside of the lid area and were not of good quality.

Standard Number / Description: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

Correction Narrative:
The operation reported the expired food items found during the site survey were discarded immediately. The Food Service Manager was notified of the expired items found. The Food Service Manager and the senior Food Service worker have re-educated all Food Service staff as of 7/6/2021 regarding the practices listed below that are to be followed on a daily basis. The education was presented individually to each Food Service worker.

	Food items are rotated with a first in, first out practice.
	When new food items are stocked, the current food items are checked for expiration.
	All food items retrieved for use are checked before use. They are checked for expiration dates, appearance and odor.
	If a food item does not have a date, it is to be thrown out.
	Cooked food that is stored is thrown out within 6 days of being cooked.
	Daily cleaning and food check of the walk-ins are completed.

The operation also reported that the Lead Cook for the day is responsible for execution of a daily cleaning checklist which includes checking for expired or compromised food. The Food Service Manager provides oversight monitoring to assure the above practices are followed consistently.


raw_content: Two children in care reported that they were served spoiled/rotten milk and that this may have been due to staff leaving the milk out of the refrigerator after use for a period of time as the milk had not been expired yet, but that it was spoiled and bad/rotten tasting. Two children in care also reported the food was not good. Staff leaving foods that should be refrigerated out for a period of time can be dangerous and may cause food-borne illnesses.

Correction Narrative:
Licensing conducted an unannounced visit to the operation and did a walk-through of the Cafeteria and Chaparral unit. Licensing checked 4 out of 4 refrigerators and 2 out of 2 freezers in the kitchen area and 2 refrigerators in the dining area of the Cafeteria near the kitchen. There were no spoiled whole milk, 1% or 2% milk, and/or soy almond milk observed. The refrigerators where the milk was stored were at proper temperatures of 40 degrees or less. Licensing also checked the refrigerator in the break room of the Chaparral unit, the almond milk and other milk was observed to not be expired, did not have a bad odor, were of normal consistency, and of good quality.

On 6/16/21, the operation also provided through email, the following compliance response:

The Director of Nursing provided re-education to nursing staff on 6/16/21 relating to safe parameters for food to be left unrefrigerated.  On 6/15/21, the Director of Nursing posted signs in the kitchen/nutrition areas with educational information related to food storage. The information includes the bacterial growth rate in milk related to temperature (obtained from USDA food safety fact sheet) and a reminder to discard any refrigerated food items after 30 minutes at room temperature.

Refrigerator temperatures are monitored and documented daily. Any out of range temperatures result in immediate action to correct the temperature. Daily checklists include inspection of refrigerator for temperatures and expired food/drinks. Expired items are discarded immediately. The checklists are forwarded to the Director of Nursing for review.

Although there were no concerns regarding the above mentioned milk products, during the walk-through, other food/drink items were observed to be expired, and/or unsealed, and/or to have mold. It was addressed with the operation that these items should be discarded and open food items should be sealed. Please refer to the follow up inspection for today's visit for further information.


facility_name: Brownson Home

summary: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

raw_content: The cottage was observed to have a strong odor of urine and uncleanliness.

Correction Narrative: The cottage was observed to be clean and no longer have any odors. The cottage was free of cliutter and there was no safety issues observed. The house parent discussed cleaning the kitchen area and maintaing the cottage to ensure the living environment is appropriiate for children.


raw_content: Two bottles of salad dressing were observed to be expired since 2022.

Correction Narrative: The refrigertor and food areas were observed to be clean and organized. The food had appropriate labels with a given expiration date. The refrigerator, stove, oven, and counter spaces appeared clean and sanitized. The house parent discussed cleaning the kitchen area and maintaing the cottage to ensure the living environment is appropriiate for children.


raw_content: There was expired food observed in the refrigerator.


summary: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old

raw_content: During the inspection, it was found that there was no medication log were compeleted for the current month and some dates were missing on other medication logs.


summary: 748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof

raw_content: During the inspection the beds didn't water prood bedding on one bed.


summary: 748.3445(b) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: During the inspeciton Cottage B refrigerator and freeze were dirty and had a broken shelf.


raw_content: During the inspection, one refrigerator and one freezer were observed to be dirty with food spills. In one home, one pan was observed in the oven to have grease from the previous day.

Standard Number / Description: 748.3445(b) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair


raw_content: During the inspection, it was found that there was no medication log for a prescribed medication.

Standard Number / Description: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old


summary: 748.3365(b)(1) - Bedding-must provide each child with a clean and comfortable mattress

raw_content: During the inspection two beds were observed without mattress covers.

Correction Narrative: During the inspection two beds had bed coverings on them.


summary: 748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate

raw_content: A screwdriver was found on the floor in one of the a child's room.

Category: Safety and Emergency Practices


summary: 748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly

raw_content: During walk thru of the cottage bug spray and sunscreen was found unsecured. There was bug spray found unsecured in the common area located outside.


summary: 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

raw_content: During the walk-thru of a cottage there was expired over the counter medication, 2 bottles of pain reliever found in the medication cabinet.


summary: 748.1501(a)(4) - Dental care-Children in care must receive dental care as needed for ongoing maintenance of dental health

raw_content: While reviewing child records it was found that a child missed the last scheduled dental appointment.

Category: Child Care

Correction Narrative: RCCR Inspector Annie Bagnato received an email from Rise Konarik from email address rkonarik@brownsonhome.org on 09/20/21. The child's dental appointment is scheduled for 9/23/21 at 8:50am. The operation plan for ensuring that appointment are made or promptly rescheduled is as follows: Staff will attempt to refrain from scheduling any appointment during final exams. Each cottage has a health, safety and emergency coordinator.  That staff will be the person responsible for ensuring that skipped/canceled appointments are promptly rescheduled or brought to the attention of the office.


facility_name: Sacred Heart Childrens Home

summary: 748.1481(a) - Release of Child-Except in emergency, only release child to parent, parent's designee, law enforcement, or person authorized by law to take child

raw_content: The operation released the child to an unauthorized person.

Correction Narrative:
Email from the operation with corrective plan.
The operation has revised policy in regarding to Affecting children's stay at the operation.  Policy was activated on January 14, 2026.  Administrator and staff will be responsible to follow through with the revised policy. Operation provided copies of the revised policy and forms and will be uploaded on Document Library.


summary: 748.685(c)(2) - Caregiver responsibility - provide a safe environment

raw_content: Staff failed to ensure the child in care was using proper safety equipment when using the skateboard to ensure his safety and well-being.


summary: 748.125(f)(1) - A PLSP must meet with a child within 24 hours of their return to an operation post hospitalization.

raw_content: Operation staff did not meet with a child in care after being hospitalized due to suicide ideations, to ensure that the placement continues to be appropriate, and that the child's need can be met.

Correction Narrative: Email received with the correction plan.   All employees received suicide prevention training on March 28, 2025. All employees' files have been update with a certificate of completion on Suicide Prevention Training.


summary: 748.125(c)(1)(C) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes the understanding of suicide screening.

raw_content: One of three employee records was found to be missing annual suicide training.

Correction Narrative:
The operation submitted corrective plan.
All employees received suicide prevention training on March 28, 2025. All employees' files have been update with a certificate of completion on Suicide Prevention Training.


summary: 748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any

raw_content: The incident report doesn't list two children in care that were present during the accident as witnesses.

Correction Narrative: The agency has provided the updated form with the required information.  The agency will provide additional training for staff to ensure the forms are correctly completed with all the required information.


summary: 748.1531(b)(2) - Medical Care-Written record of each medical examination must include the follow-up treatment recommended and any appointments scheduled

raw_content: The child in care didn't receive follow up care as recommended by the health care professional.


summary: 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication

raw_content: The medication long doesn't include the reason for why the medication was prescribed.


summary: 748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.

raw_content: One staff file had EBI training that was completed  yearly and should have been done within 6 months.

Correction Narrative: Operation submitted corrections, with plan to avoid the recurrence of deficiency in regard to the EBI training for staff. The training has been scheduled and the operation's administration will take precaution to continue scheduling the EBI training of all its staff on a timely basis.


summary: 748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling

raw_content: One staff member file did not have  documentation for verificationn of education.

Category: Personnel

Correction Narrative: Operation submitted the needed documentation for the staff member. Plan to avoid the recurrence for deficiency the operation's administrator will double check that all application is complete.


summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: Incident of child that received medical attention for injury was not reported to licensing.

Correction Narrative:
Received email from the agency.
Plan to avoid the recurrence of deficiency in reporting serious incident to licensing. Sacred Heart Children's Home administration, staff and employees will be educated in which are the incident reports needing to be reported to Licensing through the Texas Abuse and Neglect Hotline within and not later than 24hrs. of the incident. Administrator will meet with staff and employees on May 8th from 11am-12:30pm to review Minium Standards on reporting serious incidents.
 Sister Teresa Escamilla/Sister Maria Isidra Valdez will be monitoring to ensure report is followed through appropriately


summary: 748.3603(f) - Swimming-Fence gates to outdoor pool must have self-closing/self-latching hardware 60 inches from the ground and must be locked when pool not in use

raw_content: During walk through, it ws observed gate to pool area had a latch, however was not locked.


summary: 748.3421(2) - Poisons-The operation must ensure that poisonous or flammable materials are kept separate from medication, food, food prep and dining surfaces

raw_content: During walk through, four opened alcoholic beverages were observed in the refrigerator when the children's food is stored.


summary: 748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file

raw_content: During review of records, it was observed one child's file who has been in care over 30 days had no scheduled dentist visit.

Category: Admission, Service Planning, Discharge

Correction Narrative: Proof of scheduled appointment from dentist was submitted via email.


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: During review of records, it was observed one employee who is counted in ratio and has been employeed since 07/25/2022 does not has any record of EBI training on file.

Correction Narrative: Proof of completed EBI training on 10/22/2022 was submitted through email.


summary: 748.3603(a) - Swimming-The pool at the operation must be built & maintained according to the DSHS standards & any other applicable state or local regulations

raw_content: During walk-through, it was observed the pool was not maintained.


raw_content: During review of records, it was observed one employee file was missing current EBI training.  Last EBI training on file was dated for April 2021.

Standard Number / Description: 748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.


summary: 748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free

raw_content: During the walkthrough of the operation in the boys cottage three doors did not have working door knobs in the closets. In the girls cottage the tile in the playroom was found to be damaged. In the teenage cottage the room in the north side of the building on the left hand side had water damage. The dining room of the operation also had water damage.


facility_name: The Settlement Club Home GRO

summary: 748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: 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.

Correction Narrative: On 3/5/2026 a corrective action letter was received. On 3/4/2026 management met with the employee who submitted the report late. The employee acknowledged the reporting delay as a result of caretaking needs during the ice storm. The employee was educated on reporting time frames for serious incidents. On 3/17 a site inspection occurred.


summary: 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

raw_content: A caregiver was left with six children to supervise while the second caregiver took two children to the store.

Correction Narrative:
Record of correction was received by email from the operation on 1/30/2026. The caregiver involved, received counsel and additional training on 1/27/2026. The caregiver involved was informed the RTC Program ratio is 1:5 staff to resident at all times. The caregiver was informed they left their shift partner out of ratio on 12/14/2026. The caregiver was informed planning and executing all activities requires collaboration with both the shift partner and campus coordinator. Additionally, all activities must be planned in a way that maintains caregiver ratio.  Signatures of the caregiver, facilitator, and Program Director are on the document provided.
On 2/18/2026 a site inspection was conducted. During this inspection an interview occurred with a caregiver. The caregiver confirmed the ratio at the RTC is 1:5.


summary: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

raw_content: 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.

Correction Narrative:
Record of correction was received by email from the operation on 1/30/2026. The caregiver involved, received counsel and additional training on 1/27/2026. The caregiver was informed they must ensure they know where their shift partner is and how to contact them for assistance in event of an emergency. The caregiver was informed the best course of action in this situation would have been to alert the shift partner by knocking on the door. Advise of the situation and follow the child outside. The caregiver was informed they should follow the resident maintaining visual and alert the Campus Coordinator by radio. Signatures of the caregiver, facilitator, and Program Director are on the document provided.
On 2/18/2026 a site inspection was conducted. During this inspection a caregiver was interviewed on the Scarborough unit. The caregiver confirmed the location of a seatbelt cutter and a photograph was taken.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: 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.

Correction Narrative: On 12/10/2025 the operation submitted corrective action steps taken. The RTC Directors office is responsible for proofreading service plans before they are verified for completion to be sent out by the Data and Records Department. Employee's responsible for completing service plans were reminded of this protocol. A copy of the updated service plan was requested and received showing corrections.


summary: 748.1337(b)(1)(D)(i) - Initial Service Plan-Include child's personal trauma history

raw_content: 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.


summary: 748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication

raw_content: 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.

Correction Narrative: On 12/10/2025 the operation submitted corrective action steps taken. The caregiver responsible for not signing the medication records was provided feedback regarding this issue. Additionally, all caregivers were remined of the importance of signing the medication log on 12/10/2025.


raw_content: 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.

Standard Number / Description: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

Correction Narrative: On 12/9/2025 a physical site follow up was conducted. Shaving razors were observed to be locked in the office closet and a photograph was taken. The "sharps" check out log was located on the wall in the staff office, and none were checked out at the time. A photograph was taken. During the inspection of the cottage, no shaving razors were located. On 12/11/2025 a corrective steps taken by the operation was submitted. All staff were retrained on the policy of signing in and out "sharps" and reminded about the seriousness of keeping track of these items. The training occurred on 12/10/2025 by the RTC Director.


summary: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

raw_content: The medication log and medical incident report showed that a child in care received 2 doses of a medication instead of 1 as prescribed.

Correction Narrative:
An email was received 11/14/25 from the operation stating the following: In response to the above deficiency regarding administration of medication, all RTC staff were re-trained on RTC protocols regarding setting and administering medications on 11/5/25 and then given an additional training on medication documentation with the medical team on 11/12/25. The staff member who committed this error no longer works at The Settlement Home.
On 11/10/2025 a site inspection was conducted. Two random sample medication log and count test were conducted on two different residents.


summary: 748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision

raw_content: 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 .

Correction Narrative:
On 9.15.25 the department received the compliance plan from the operation. RTC Director stated that they were having technical issues on Friday 9.12.25 and emails could not be sent. The compliance plan states the following:

In response to the deficiency regarding caregiver responsibility and supervision during a group activity in the campus courtyard, all RTC staff were re-trained on RTC protocols regarding number of residents in the courtyard at a time , being aware of youth who are in the vicinity of each other, and relevant safety plans. The staff members present during the incident were given written feedback by the Therapist Supervisor on 8.25.25 and an additional training was presented on 8.27.25 to all RTC staff members.


summary: 748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: 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.

Correction Narrative: In response to the deficiency, regarding food preparation and storage, the settlement home has implemented a checklist for cooks on campus regarding food preparation and storage, the Settlement Home has implemented a checklist for cooks on campus regarding food preparation areas to ensure compliance at all times. When a staff member goes on break or leaves for the day, they will be required to complete the checklist prior to clocking out. This will be implemented immediately.


summary: 748.3441(n) - Food Preparation-Food must be protected from contamination

raw_content: During  the inspection, I observed food containers not properly stored and food not properly covered or put away.


summary: 748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor

raw_content: Durning the investigation, food boxes were stored on the floor of the walkin freezer.


raw_content: 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.

Standard Number / Description: 748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision

Correction Narrative: All staff members given re-training on seating assignments and potential high risk behaviors during transportation and off-campus outings, including that residents should leave space between them if able to during van rides and that staff members should spread out to ensure supervision when more than one staff present. Staff members were reminded that safety plans must be checked prior to leaving for off-campus and encouraged staff to set seating assignments for the van in advance to prevent potential for unsafe behaviors during off campus. Date: 8/13/25


summary: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment

raw_content: 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.

Correction Narrative: The staff  involved in this incident are no longer employed by the operation or were placed on a performance improvement plan


summary: 748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person

raw_content: During an investigation it was discovered a child in care was given another child in care's medication.

Correction Narrative: The operation completed a mandatory all staff training in regards to medication on 04/24/202.  Any staff that did not attend will be required to do so.


summary: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

raw_content: 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.

Correction Narrative: Settlement Home is completing an all-staff medication retraining on proper protocols for ensuring medication is taken as prescribed and any errors are documented within 24 hours.  The training is scheduled for 04/23/25.


summary: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

raw_content: During an investigation, it was found multiple medications were not being given as prescribed.


summary: 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

raw_content: The operation has allowed a staff member to smoke in an area that is not a safe distance from the children's living area.

Correction Narrative: The operation modified policy to ensure staff are not in any child's vision when using tobacco or tobacco products as well as now reflecting that the staff will also be at least 15 feet from any entrance or exit of a building to ensure that no children are exposed to tobacco products.  No cigarette butts were noted during a walkthrough around all units.


summary: 748.2101(1) - Medication Storage-Store medication in a locked container

raw_content: During the inspection, the medication cart was not locked at the Moody Cottage staff office.


raw_content: Through interviews with staff and reviewing documentation, it was determined that signatures on medications logs were forged, and a therapy note contained inaccurate information.

Standard Number / Description: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

Correction Narrative: An email was received from the RTC Director. In response to maintaining true and accurate records, staff members were given corrective feedback around never forging signatures on any documents and given other strategies to achieve compliance in the medication book. Further, the therapist responsible for the therapy note was given corrective feedback on 12-2-24 ensuring that dates on all therapy notes are correct and accurate when completing them. An in-person inspection was conducted on 12/9/24. The medication book was reviewed for 2 children in care. Signatures were complete and there were no concerns regarding the medication log.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: Through interviews it was determined that staff are cursing when talking to other staff and children in care can hear it.

Correction Narrative: An email was received from the RTC Director. In response to cursing in front of residents, feedback was given to multiple staff members working at the cottages after cursing was reported. Staff were informed that staff are never permitted to curse in front of residents and that measures should be taken to prevent this.  An in-person inspection was conducted on 12/9/24. Interactions between staff and children were held. Interviews were held with 3 staff and 2 children and report no instances of staff cursing. There were no concerns regarding staff using profane language.


raw_content: 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.

Correction Narrative: The cottage staff responsible for this incident will be retrained on 12/18/24 on how to create a safety plan and share it with campus in the event that a child engages in or is at risk of engaging in a high-risk behavior.


raw_content: On 7/18/2024 six residents were not provided their morning medications.

Standard Number / Description: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed

Correction Narrative: The operation completed medicaiton training in regards to how to give medication as well as store it on 07/31/24.  Staff indicated there had been a training when spoken with.


raw_content: 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.

Standard Number / Description: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks


summary: 748.2009(a)(2) - Inform child's prescribing health-care professional of administration/dosage of any non-prescription medications or supplements

raw_content: 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.

Correction Narrative: On 7/31/2024 twenty-nine staff were required to participate in a training titled "Set It, Don't Forget It" Medication Compliance Refresher. The training covered medication procedures, resident allergies and protocols on administering medications. The training also covered allergies at the operation and Epi-pen administration. The staff were all required to personally sign into class on a form. A roster of staff for this training was received.


summary: 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures

raw_content: During the investigation, it was made known that a staff member did not follow the operations policies when administering medications.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: Three residents at the operation described seeing a staff member sleeping in the office on three separate occasions during the night hours.

Correction Narrative: Staff member at the operation has been placed on a 60-day plan in which they will log into a computer and sign that checks have been completed every 15 minutes aprox. These signatures are time stamped by the computer and not modifiable. Supervisors will check the signature sheets after the shift. The signature sheets will remain on file for review.


summary: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below

raw_content: 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.

Correction Narrative:
On 5/23/24, the operation provided an email to licensing with a follow up response reporting that in order to ensure that thermometers at Casa Sara are not accidentally removed from refrigerators, they are now attached to the inside of the refrigerators and freezers by zip ties. The concern about the temperatures of the freezers was addressed by our maintenance team who assessed and repaired all equipment so that it is in working order. The operation provided 4 photos. The pictures display all 4 thermometers in the two refrigerators and freezers. The thermometers are connected with zip ties and reflect temperatures required by Standard/Rule 748.3443(b)(1). In the photos the temperatures show to be at 0 degrees and 32 degrees for unit 1 and 10 degrees and 32 degrees for unit 2.

On 6/21/24, the assigned licensing rep contacted the operation by phone and reviewed the follow up compliance with them as well.


summary: 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

raw_content: 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.

Correction Narrative: An email was received from the RTC director.  The Settlement Home will complete the following actions. All therapists have a new requirement that notes should be complete by the 10th of the following month to ensure timely completion of these notes. Additionally, a Performance Improvement Plan will be created for the therapist involved in this investigation to ensure that all sessions are being completed on a weekly basis.


raw_content: During the course of this investigation, it was determined that a staff member used inappropriate language in the presence of children in care.

Correction Narrative: The operation trains employees extensively in this area. The specific employee named in the investigation was put on a Performance Improvement Plan and when no improvements were made, was terminated.


summary: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

raw_content: 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.


summary: 748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair

raw_content: 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.

Correction Narrative: The couches were observed to have patches and covers on them during the walk through.


summary: 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

raw_content: 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.

Correction Narrative:
4/9/24 the operation emailed a compliance plan for this violation. The plan consisted of conducting a walkthrough of all cottages and the campus dining hall targeting expired foods and any items of concern were thrown out. Cottages will continue to check expiration dates on Wednesdays and Saturdays and before grocery shopping. All staff were re-trained in the licensing standards regarding food prep and storage. Additionally, a new system of food ordering was put in place to minimize the need to long-term freezing or storage of foods.
4/24 Pictures were taken of all the refrigerators and they did not contain uncovered or expired food items.


summary: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

raw_content: 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.

Correction Narrative: During the walk though the refrigerators did not contain any expired food items.


summary: 748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator

raw_content: During a walkthrough of the operation several food items were being stored in the cottage refrigerators with no lid or cover.

Correction Narrative: 4/9/24 the operation emailed a compliance plan for this violation. The plan consisted of conducting a walkthrough of all cottages and the campus dining hall targeting expired foods and any items of concern were thrown out. Cottages will continue to check expiration dates on Wednesdays and Saturdays and before grocery shopping. All staff were re-trained in the licensing standards regarding food prep and storage. Additionally, a new system of food ordering was put in place to minimize the need to long-term freezing or storage of foods.


summary: 745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions

raw_content: 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.

Correction Narrative: The operation sent an email response stating that Ms. Brownlee would not be caring for children alone, transporting children, or administering medications until the out of state background check cleared. The background check was cleared on 12/29/23; however Ms. Brownlee was placed in an inactive status at the operation on 1/3/24.


summary: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

raw_content: 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.

Correction Narrative: The operation reported to more supervisory walk thru/check ins around med setting times to ensure all medication protocols are being followed. Retrain staff regarding setting and administering the medications. A walk through of the cottage was completed and medication evaluated.


summary: 748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety

raw_content: 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.

Correction Narrative: Interviews were conducted with operation management, staff and children in care. All persons interviewed confirmed daily supervision meet the needs for the children in care.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: 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.

Correction Narrative: CCR conducted an inspection of medication storage areas and found all be secured with double locks.


raw_content: 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.

Standard Number / Description: 748.2101(1) - Medication Storage-Store medication in a locked container

Correction Narrative: A walk through was conducted at various cottages and medication assessed and found to be secured as required.


summary: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

raw_content: In an investigation conducted by DFPS, one staff was confirmed to have medically neglected and neglectfully supervised a child in care.

Correction Narrative: A follow up was conducted with RTC Director. Director reported to have conducted a full review of medication protocols with all staff in the cottage where the incident occured. RTC director reported  that the medication will be prepared in the houseparent room behind the staff office. Interviews were conducted with staff to confirm protocols for medication and supervision were reviewed.


summary: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance

raw_content: 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.

Correction Narrative: Staff was interviewed during the follow up and a written compliance plan was provided as well that entailed a review with the staff that was driving, a performance plan, and the staff is not currently transporting children.


summary: 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

raw_content:
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

Correction Narrative: All staff members participated in a training conducted on 9/20/23, where standards related to restraint documentation were reviewed. In this training, documentation for serious incidents, including physical intervention, was reviewed as well as the requirements for notifying guardians for physical interventions.


summary: 748.2855(a)(10) - EBI Documentation-Must include all attempts to explain to the child what behaviors were necessary for release from the intervention.

raw_content: 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.


summary: 748.685(b)(5) - Caregiver responsibility - when deciding how close to supervise, takes into account the child's physical, mental, emotional, and social needs

raw_content: 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.

Correction Narrative: The operation has put a plan in place for the staff involved which entails coaching and training in both the RTC in addition to the group home, which is her usual employment placement.


summary: 748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required

raw_content: 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.

Correction Narrative:
The department received an email from the operation stating the following:

The Settlement home has taken the following steps.
Cottage Supervisors and Program Directors will increase scrutiny of service plans to ensure that information is clear in consistent regarding a resident's supervision. Additionally, all cottage staff members at the Meadows Cottage will be provided increased training on how to read and interpret safety plans to ensure that all decision regarding activity participation are consistent with a resident's supervision and safety requirements.


summary: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

raw_content: 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 .


summary: 748.705(b)(3) - Reasonable & prudent parent standard-must consider the child's behavioral history and ability to safely participate in proposed activity

raw_content: The daily progress note dated 3 days prior to the incident stated the child had high risk suicidal and runaway ideations. The childs 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.


summary: 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.

raw_content: One of the ten Serious Incident Reports read were not reported to the Intake Line as required when police responded to the facility.

Correction Narrative: RTC Program director sent a compliance plan stating that their organization had changed the reporting criteria for mental health assessments conducted by mental health officers since they would not result in criminal charges being filed against the youth; however in lieu of the current citation the operation will inform staff at an all staff meeting on 5/10 that any visit at the operation by a police officer, must be reported.


summary: 748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication

raw_content: Staff administered a restraint in a non-emergency situation in order to obtain a THC and nicotine vape from a youth in care.

Correction Narrative: Staff were given a directive and training on 6/7/23 regarding when to enter a restraint and what constitutes an emergency situation. Post tests were reviewed to ensure staff understood and could articulate what an emergency situation entails.


raw_content: An overnight caregiver was noted to be sleeping during their shift.

Correction Narrative: Based on interviews with staff and children, the operation has superiors that oversee the night staff and make regular contact to ensure the staff is awake.A performance plan was implemented for this particular staff; subsequently, sufficient progress was not attained and the employee was terminated.


summary: 748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period

raw_content: One out of three staff files reviewed did not have current annual training in Normalcy, TIC, Psychotropic medication, and Reporting abuse and neglect.


summary: 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

raw_content: 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 childs 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.

Correction Narrative: The operation provided a completed version of the Serious Incident Report to RCCR Inspector.


raw_content: 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.

Standard Number / Description: 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

Correction Narrative: The operation provided written notification to the CPS caseworker on December 13, 2022.


summary: 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication

raw_content: A child was able to gain access to ibuprofen that was being stored in a safety bag

Correction Narrative:
An email was received from the operation stating the following compliance plan:

All staff members were informed that First Aid Kids should not be included in the Safety Bags nor should they be kept anywhere children may have access to supplies or medication.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: 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.

Correction Narrative:
An email was received by the operation. The window in question was repaired immediately following the incident and all staff were informed of their duty to report issues in need of repair through the campus work order system.
This Inspector completed a walkthrough on 8.5.22, the day after the incident occurred, and the window in question had been fixed. A picture is uploaded to digital storage.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: 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.

Correction Narrative: An email was received by the operation. All staff were reminded and re-trained on the importance of keeping office doors closed when staff are outside the office, in addition to utilizing locks to prevent residents from attempting to enter the office.


summary: 748.2151(e) - Medication Record-must document non-prescription medication or supplement given to child and how often given

raw_content: 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.


summary: 748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator

raw_content: The refrigerator located in CASA SARA had opened food items that were not stored in proper storage containers.

Correction Narrative: All food stored in the refrigerator was stored in properly sealed containers.


summary: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

raw_content: 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.

Correction Narrative: Medication was being used as perscribed.


summary: 748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions

raw_content: Medication was found in clear ziploc bags and not in the original container.

Correction Narrative: Medication was being stored in origninal containers.


summary: 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

raw_content: It was identified 17 medication incident reports, used to document medication errors, were not documented within 24 hours.

Correction Narrative: Licensing received an email from the operation with the 17 corrected medication incident reports used to document medication errors.


summary: 748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old

Deficiency Narrative: 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.

Correction Narrative: All prescription medication dispensed  had staff signatures and the dosage dispensed to each child.


summary: 748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: 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.

Correction Narrative: Settlement Home has invested in a complete kitchen renovation for all three RTC cottages. The cottage where the deficiencies occurred, started renovations on 6/27. The cabinet door was repaired, the counter tops and stove tops were cleaned, and the food  was removed from the bottom of the freezer. Staff were reminded of cleanliness and chore expectations.


summary: 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

raw_content: 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.

Correction Narrative: An email was received from the operation. Settlement has created 3 additional direct care positions at each RTC cottage to increase the number of staff responders in emergency situations to prevent the need for staff to leave their cottage out of ratio.


raw_content: 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.

Standard Number / Description: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

Correction Narrative: An email was received from the operation. Feedback was given to the staff involved regarding the level of supervision determined for the youth and situation in question. They were instructed to seek additional consultation when making these decisions in the future.


summary: 748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards

raw_content: 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.

Correction Narrative: Administrator sent an plan stating members of the maintenance team will complete daily visual campus sweeps to identify irregular hazards and select supervisory still will complete weekly walkthroughs to include outdoor areas. Staff will also complete thorough walkthroughs twice monthly. Walkthroughs will be completed more frequently upon request or if necessary due to a specific need.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: 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.

Correction Narrative: The medication carts being unlocked will be discussed with staff in supervision to ensure all staff know the seriousness of leaving the cart unlocked when not in use.


raw_content:
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.

Standard Number / Description: 748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator


summary: 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

raw_content: It was identified during this investigation that a male staff member entered a bathroom while a female child in care was showering.

Correction Narrative:
Safety Plan for Boundaries between Male Staff and Residents

June 7, 2022

 All male staff will review the policies in place regarding appropriate boundaries between male staff and Settlement Home residents no later than during their next meeting with their direct supervisor.
 This review will include when it is appropriate to enter resident bathrooms when in use. Male staff should always seek out the assistance of a female staff to check on a resident or address an issue in a bathroom that is in use except in the cases of true emergencies where the safety of the resident is at immediate risk.
 The above topics will be reviewed in an individualized training for the involved employee during the employee's individual supervision on June 7, 2022.


raw_content: 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.

Standard Number / Description: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

Correction Narrative: Letter from the operation: The primary staff supervising the outing was terminated and the other staff is no longer with the operation. All staff were provided re-training on the importance of medication management to minimize errors and enhance child safety


summary: 748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.

raw_content: 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.

Correction Narrative:
The operation emailed RCCR and explained on March 7 2022, staff were notified in writing of the 30-minute restraint time limit. On March 9, 2022, staff were verbally notified during an all staff training. Additionally, all written policies and EBI documentation materials were reviewed to ensure compliance and were reviewed by the Compliance Director and Training Coordinator to ensure this was correctly taught in all Pre-Service and ongoing trainings.

TA was given to the operation on 3.4.22 for this standard.


summary: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

raw_content: A direct care worker has been working at the operation with an inactive background check since June 2021.

Correction Narrative: The operation took the caregiver off the schedule, beginning immediately, until their background check is reran. The background check is active as of 1.13.22.


summary: 748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: 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

Correction Narrative: Operation sent an email stating their plan going forward is to ensure they are meeting the reporting requirements for staff and residents who contract a reportable infectious disease.  They have reviewed the requirements with staff that they must report their positive COVID-19 test results to their supervisor, or the supervisor on call if after hours or on the weekend.  All supervisors are aware of the reporting requirements and will ensure that the reports are made within the required time frames.


summary: 748.2307(4) - Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse

raw_content: The investigation concluded that a staff used  condescending and sarcastic comments towards a child in care.

Correction Narrative: On 01/27/2022 the operation provided follow up and reported due allegations about the staff member's conduct, the staff's employment was terminated on 12/28/2021.


summary: 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

raw_content: 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.

Correction Narrative: During the follow-up inspection it was observed that all expired medication was disposed of properly and any medication needing to be refilled/reordered was completed.


summary: 748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid

raw_content: One employee who is counted in ratio, did not have first aid training.

Correction Narrative: The employee emailed proof of her First aid and CPR training and is now compliant.


summary: 748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly

raw_content: 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.

Correction Narrative: Email from Director McKay stating the following: In response to the deficiency we have moved the dishwasher detergent to a locked cabinet and we have reviewed with all staff members about the importance of using the nightly checklist to ensure all sharps have been turned back into staff and have been signed out appropriately. This incident specifically was a documentation issue where staff did not sign that the sharps had been returned, however the sharps were returned and in a safe location.


summary: 748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously

raw_content: It was determined a child in care was denied a request to contact the Texas Abuse Hotline.

Correction Narrative: On 7/19/2021 Settlement Home made changes to their protocol for allowing children in care to make private calls to the ombudsman and the DFPS Hotline 24 hours a day free from observation. Campus supervisors were informed of the changes made the same day. On 7/28/2021 all staff were re-trained on these changes. Pre-service training has been updated to ensure that new staff are aware of the phone protocols that allows children in care to make calls to the ombudsmen and the DPFS hotline upon request.


summary: 745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving

raw_content: 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.

Correction Narrative: Received call from Trena Robinson (Human Resource Manager) around 6:30 pm stating she would immediately be inactivating the background check. Review of the Online BGC showed the needed background was made inactive as of this date.


summary: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

raw_content: One of the toilets in the Nelson Cottage was observed with at least a half inch circle of mold and mildew around the inside rim of the toilet and a secondary circle of mildew was observed around the water line inside the toilet. The sink in that same bathroom was observed to have some type of brown and red dried up splatters. On June 4 the administrator incdicated that the bathrooms in Nelson Home were in need of deep cleaning.

Correction Narrative: On 6/29 I received an email from the RTC Director that stated that a deep clean was initiated in response to the citation under the supervision of the RTC Director. Staff were re-trained regarding deep cleaning and bathroom chore expectations. A photo was sent of both the toilet and sink after it had been cleaned to show compliance was met. A physical follow up was also conducted on 7/5/21 and toilet and sink were clean and free of splatter, mold, and mildew.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: Five individuals interviewed acknowledged witnessing staff, who acknowledged being responsible for checking on the children, sleeping during their shift.

Correction Narrative: The staff involved in this citation was terminated. This was noted as an isolated incident.


summary: 748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety

raw_content: 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.

Correction Narrative: All staff were retrained on checking on children. All window alarms and door alarms were checked and ensured to be working.


summary: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

raw_content: During the course of the investigation it was determined there was an issue with mold/mildew in the children's shower.


summary: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

raw_content:
It was found that on 5/6/21, the child/victim was supposed to be using the front bathroom in the cottage to shower according to the safety plan in place (as of 4/29/21) and according to collateral reports, however the child switched bathrooms with another resident without staffs' knowledge or awareness. The child/victim went to shower in own bathroom instead and ended up falling and hitting their forehead on the bathroom counter and was taken to the hospital.

According to the safety plan and collateral reports, the child was supposed to also be getting checked on every 5 minutes while showering due to safety concerns, however staff were not aware of the two children switching bathrooms until after child/victim informed one of the cottage staff of falling and hitting their head. It was reported, the staff that the child informed had left the cottage to run errands on campus and had returned after approx. 20 min. while the other staff had remained at the cottage.


summary: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

raw_content: A caregiver did not demonstrate self-control when they  became angry and yelled in front of the children and slammed doors.

Correction Narrative: Caregiver was reminded of both acceptable and prohibited interventions and effective de-escalation techniques and was provided additional applicable training opportunities. A review of Milieu Management training and formal training of efficient de-escalation techniques was provided. A performance plan has also been implemented.


summary: 748.2301(b)(5) - Disciplinary Measures-must be appropriate to the incident and severity of the behavior demonstrated

raw_content: During interviews with staff and residents, it was determined that one staff member is imposing consequences on children in care that is excessive for the behavior that the children demonstrated. This staff is also not consistent with giving consequences.


raw_content: A child in care who was placed in this cottage to stabilize for unsafe behaviors was able to access a metal bracket for a shelving unit in an unlocked closet, a staple from the wall and a butter knife from the kitchen. The child made some superficial cuts to their arm and also ingested cleaning chemicals. During this time, a staff member who was responsible was reportedly outside of the cottage and unable see the child. They also reported that while the therapist was on the unit, was not told to supervise the child.

Correction Narrative: An inspection was conducted on 4/20/2021 and this standard was found to be in compliance during that inspection.


raw_content: The closet where cleaning chemicals are stored was unlocked and open, allowing a child the opportunity to take one and ingest it.

Standard Number / Description: 748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly

Correction Narrative: The cleaning supply closet was found to be locked.


facility_name: Gulf Coast Trades Center

summary: 748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization

raw_content: Information obtained during the investigate evaluation indicates that serious incident reporting to Licensing was not completed within the 24-hour timeframe after a child received treatment by a medical professional, in accordance with Minimum Standards.

Correction Narrative:
On 02/06/2026, the operation administrator submitted corrective action via email to Licensing, confirming that staff will comply with required timelines for contacting the intake hotline.

The administrator also noted that the operation will be requesting an administrative review.


raw_content: The toilets and showers have not been properly cleaned and the children mattresses are worn and patched with duct tape.

Standard Number / Description: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

Correction Narrative: This standard was found to be in compliance during a follow-up inspection.


summary: 748.1691(b)(2) - Nutrition-Must not be more than 14 hours between last meal or snack of the day and the serving of the first meal of the following day

raw_content: Meal periods on the weekend are 15 hours apart as dinner is at 5pm and Breakfast is at 8am.