Deficiencies (over last year)
Deficiencies (over last year)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 9
Date: Jun 8, 2022
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 with deficiency history related to health and life safety codes.
Findings
The facility had multiple violations cited in health and life safety codes during inspections in early and mid-2022, with several deficiencies corrected and some pending.
Deficiencies (9)
The facility failed to search the NAR and EMR annually.
The facility failed to correct a site or building condition that was a fire, health, or physical hazard.
The facility failed to conduct required fire drills and document fire drills on the required form.
The facility failed to notify HHSC in writing prior to the start of building rehabilitation.
The facility failed to provide required emergency lighting.
The facility failed to develop and maintain a written emergency preparedness and response plan based on its risk assessment and adequate to protect residents and staff in a disaster or emergency.
The facility's emergency preparedness and response plan failed to address the eight core functions of emergency management.
The facility failed to review the emergency preparedness plan at least annually and after disasters, drills, or policy changes.
The facility failed to ensure means of egress met the referenced codes and standards.
Report Facts
Inspections on page: 2
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