You may remember the viral photo of a woman in a wheelchair, waist deep in flood water, at the La Vita Bella nursing home in Dickinson.
RELATED: Dozens rescued from nursing home underwater in Dickinson
The report says the incident happened because the facility was not evacuated in a timely manner. They were fined $550.
"State leaders, assisted living facility operators, and the public should heed the lessons of Hurricane Harvey to avoid similar problems in the future," said AARP Texas Director Bob Jackson. "As the hurricane season moves into a more dangerous phase, we need to keep a watchful eye on these vulnerable Texans and take the necessary steps to protect them."
Three other assisted living facilities were also cited after the hurricane.
Lakewood Personal Care
- The facility was only cited for 14 residents, but 21 individuals were found to be sleeping there when inspectors visited.
- One resident had an 8 inch long and 5 inch wide wound that was "bloody, open and had pus," according to the report. His wound had reportedly been healing until it "reopened when he walked through flood waters."
- State Inspectors reported that the facility's inner walls were not repaired after the flood, which inspectors say placed residents at risk of health issues.
Lakewood Personal Care 2
- The facility did not have an emergency preparedness and response plan.
- Residents were left unattended during Hurricane Harvey.
- Residents were evacuated to the George R. Brown Convention Center where they stayed for three weeks. The facility was fine 1,000.
- Four days before Hurricane Harvey the City of Victoria had issued a mandatory evacuation order. The facility evacuated all residents except one.
- According to state inspection documents, once in Cedar Park, facility administrators realized that someone had been forgotten. Administrators called the Victoria Police Department, who entered the facility and found the forgotten resident in her locked room. She was transported by EMS to a local hospital.
- Inspection reports show the administrator failed to follow the facility's own plan and did not report the incident to the state, as is required by law. Two violations were substantiated, but no fines were assessed.
La Vita Bella
- According to the state inspection documents, the administrator of La Vita Bella made the decision to have residents shelter in place. When flood waters began filling the facility and it was necessary to evacuate, none of the vehicles identified in the emergency preparedness and response plan were on site.
- Texas HHSC investigators found that the facility also had a contract with an ambulance company that requires 72 hours' notice for evacuation. The Texas HHSC inspection report states that failure to initiate evacuation in a timely manner resulted in residents sitting in waist-deep flood water for hours, awaiting rescue.
- Nearly eight hours after the facility began to flood, help arrived in the form of a resident's family member, who brought a boat and was able to use plastic-covered mattresses to transfer four residents from the facility to a local hospital. Meanwhile, the other 11 residents were evacuated by two Army trucks from Texas City. These residents were taken to temporary shelters before being moved to a nursing facility. The facility was fined $550.