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🔎 Lbj Medical Center

Inspection Results


Inspection Overview

Lbj Medical Center has been cited for a total of 61 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-12-31
Correction Date: 2025-01-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-10-30
Correction Date: 2024-10-31
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: K

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2024-10-30
Correction Date: 2024-10-31
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Survey Date: 2024-09-06
Correction Date: 2024-09-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-07-30
Correction Date: 2024-07-31
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2024-06-19
Correction Date: 2024-06-25
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Survey Date: 2024-06-19
Correction Date: 2024-06-25
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2024-02-15
Correction Date: 2024-02-16
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2024-02-15
Correction Date: 2024-02-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2024-02-15
Correction Date: 2024-02-16
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2024-02-15
Correction Date: 2024-02-16
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2024-02-15
Correction Date: 2024-02-16
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-02-15
Correction Date: 2024-02-16
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-11-22
Correction Date: 2023-12-07
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2023-06-19
Correction Date: 2023-08-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: C

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Survey Date: 2023-06-19
Correction Date: 2023-08-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-05-09
Correction Date: 2023-05-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-01-13
Correction Date: 2023-02-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2023-01-13
Correction Date: 2023-02-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: K

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-01-13
Correction Date: 2023-02-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-01-13
Correction Date: 2023-02-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2022-10-17
Correction Date: 2022-10-18
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-08-18
Correction Date: 2022-08-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-08-18
Correction Date: 2022-08-19
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-05-19
Correction Date: 2022-05-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-05-19
Correction Date: 2022-05-20
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: G

Honor each resident's preferences, choices, values and beliefs.

Survey Date: 2021-11-19
Correction Date: 2021-11-20
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: K

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Post nurse staffing information every day.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Keep all essential equipment working safely.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Survey Date: 2021-10-27
Correction Date: 2021-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-08-06
Correction Date: 2021-08-27
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Survey Date: 2021-07-02
Correction Date: 2021-07-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2020-11-25
Correction Date: 2020-12-23
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2020-11-25
Correction Date: 2020-12-23
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2020-11-25
Correction Date: 2020-12-23
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2020-11-25
Correction Date: 2020-12-23
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2019-09-26
Correction Date: 2019-10-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-09-26
Correction Date: 2019-10-02
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Keep all essential equipment working safely.

Survey Date: 2019-09-26
Correction Date: 2019-10-07
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**