Complaints and Deficiencies Fiscal Year 2013

Note: Fiscal year (FY) 2013 began Sept. 1, 2012, and ended Aug. 31, 2013. Source: Texas Department of Aging and Disability Services Regulatory Services Fiscal Year 2013 Annual Report.

Top 10 Most Frequent Complaint Intake Reasons

  1. Neglect — Failure to provide services, treatment or care that causes or could cause mental or physical injury, or harm or death to the resident. (Ranked No. 1 in fiscal year 2012)
  2. Resident Rights/Client Protections — Failure to ensure that residents have autonomy and choice, as far as possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. (Ranked No. 2 in fiscal year 2012)
  3. Activities of Daily Living — Failure to provide necessary care and services to maintain or prevent deterioration in a resident's ability to bathe, dress, groom, transfer, ambulate and toilet unless the deterioration was unavoidable; or, failure to provide residents who are dependent on staff to meet their activities of daily living all the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. (Ranked No. 3 in fiscal year 2012)
  4. Quality of Care — Failure to provide services that improve (or at least maintain) a resident's overall physical and mental condition as indicated by the resident's comprehensive assessment. (Ranked No. 4 in fiscal year 2012)
  5. Quality of Life — Failure to care for residents in a manner and in an environment that promotes maintenance or enhancement of each resident's dignity and selfdetermination about aspects of his or her life in the facility that are significant to the resident. (Ranked No. 5 in fiscal year 2012)
  6. Medications — Failure to ensure that residents' medications are administered in the correct dosage as prescribed by the physician; or failure to ensure a resident's drug regimen is free from drugs used in excessive dose or duration, without adequate monitoring, without adequate indications for their use, in the presence of adverse consequences that indicate the dose should be reduced or discontinued. (Ranked No. 6 in fiscal year 2012)
  7. Environment — Failure to provide a safe, clean, comfortable and homelike environment with everything in proper working order. (Ranked No. 7 in fiscal year 2012)
  8. Sufficient Staff — Failure to provide sufficient qualified and trained staff to care for residents to enable them to reach their highest practicable physical, mental and psychosocial well-being. (Ranked No. 8 in fiscal year 2012)
  9. Dietary Services — Failure to provide nutritious, appealing and sufficient food and drink according to a resident's needs and desires, and to prepare and serve food utilizing acceptable food handling. (Ranked No. 10 in fiscal year 2012)
  10. Pressure Sores — Failure to prevent pressure sores from developing on residents, or to provide sufficient care to heal pressure sores that a resident may already have on admission. (Not ranked in fiscal year 2012)

Top 10 Program Deficiencies Cited During Inspections (Certification)

  1. Infection Control, Prevent Spread, Linens: 42 CFR 483.65, TAG 0441 — The facility did not have a program to keep infection from spreading. (Ranked No. 1 in fiscal year 2012)
  2. Food Procure, Store/Prepare/Serve −Sanitary: 42 CFR 483.35(i), TAG 0371 — The facility did not get food from approved places and store, cook, and give out food in a safe and clean way. (Ranked No. 3 in fiscal year 2012)
  3. Pharmaceutical Service−Accurate Procedures, RPH: 42 CFR 483.60(a),(b), TAG 0425 — The facility failed to obtain and provide drugs as needed or use the services of a licensed pharmacist. (Ranked No. 2 in fiscal year 2012)
  4. Nurse Aide Demonstrate Competency/Care Needs: 42 CFR 483.75(f ), TAG 0498 — The facility did not make sure that nurse aides show they have the skills to be able to care for residents. (Ranked No. 5 in fiscal year 2012)
  5. Free of Accident Hazards/Supervision/Devices: 42 CFR 483.25(h), TAG 0323 — The facility did not make sure that the nursing home area is free of dangers that cause accidents. (Ranked No. 4 in fiscal year 2012)
  6. Develop/Implement Abuse/Neglect, Policies: 42 CFR 483.13(c), TAG 0226 — The facility did not write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. (Ranked No. 7 in fiscal year 2012)
  7. Other Environmental Conditions: 42 CFR 483.70(h), TAG 0465 — The facility did not make sure that the nursing home area is safe, easy to use, clean and comfortable. (Ranked No. 9 in fiscal year 2012)
  8. Provide Care/Services for Highest Well-being: 42 CFR 483.25, TAG 0309 — The facility did not give each resident care and services to get or keep the highest quality of life possible. (Ranked No. 6 in fiscal year 2012)
  9. Resident Records−Complete/Accurate/Accessible: 42 CFR 483.75(l)(1), TAG 0514 — The facility did not keep accurate and appropriate records. (Ranked No. 8 in fiscal year 2012)
  10. Drug Records, Label/Store Drugs & Biologicals: 42 CFR 483.60(b),(d),(e), TAG 0431 — The facility failed to properly store and label drugs. (Not ranked in fiscal year 2012)

Top 10 Life Safety Code Deficiencies Cited During Inspections (Certification)

  1. Life Safety Code Standard: NFPA 101, TAG 0067 — The facility failed to meet requirements for air conditioning and ventilating equipment. (Ranked No. 1 in fiscal year 2012)
  2. Life Safety Code Standard: NFPA 101, TAG 0038 — The facility failed to ensure that arrangements of exits are provided and/or maintained such that exits are readily accessible at all times. (Ranked No. 2 in fiscal year 2012)
  3. Life Safety Code Standard: NFPA 101, TAG 0025 — The facility failed to provide smoke walls that provide required fire-resistance rating. (Ranked No. 3 in fiscal year 2012)
  4. Life Safety Code Standard: NFPA 101, TAG 0062 — The facility failed to ensure that the required sprinkler systems are maintained in reliable operating condition and are inspected and tested periodically. (Ranked No. 5 in fiscal year 2012)
  5. Life Safety Code Standard: NFPA 101, TAG 0147 — The facility failed to ensure that electrical wiring and equipment is in accordance with NFPA standards and national electrical codes. (Ranked No. 4 in fiscal year 2012)
  6. Life Safety Code Standard: NFPA 101, TAG 0029 — The facility failed to separate hazardous areas by construction that provides at least a one-hour fire resistance rating and/or a sprinkler system as specified by the Life Safety Code. (Ranked No. 6 in fiscal year 2012)
  7. Life Safety Code Standard: NFPA 101, TAG 0018 — The facility failed to ensure that doors protecting corridor openings are substantial enough to resist fire for at least 20 minutes. (Ranked No. 7 in fiscal year 2012)
  8. Life Safety Code Standard: NFPA 101, TAG 0144 — The facility failed to inspect and test its generators as required by NFPA 99. (Not ranked in fiscal year 2012)
  9. Life Safety Code Standard: NFPA 101, TAG 0069 — The facility failed to provide commercial cooking equipment that meets the requirements of the National Fire Protection Association. (Ranked No. 10 in fiscal year 2012)
  10. Life Safety Code Standard: NFPA 101, TAG 0051 — The facility failed to ensure that the fire alarm system meets the functional requirements of the Life Safety Code. (Ranked No. 8 in fiscal year 2012)

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Updated: October 15, 2014