Inspection Report — Aug 15, 2025
Citations: 24
Date: Aug 15, 2025
Visit Reason
State-compiled facility profile showing 24 citations across 2 inspection dates with deficiency history.
Findings
The facility was cited for 24 violations including 18 health code citations from the most recent inspection on 2025-08-15 and 6 life safety code citations from a prior inspection on 2020-02-13. Many health code violations remain pending correction while all life safety violations were corrected in 2020.
Citations (24)
The facility failed to have sufficient staff to assure that each resident would receive the kind and amount of supervision and care required to meet basic needs.
The facility failed to conduct criminal history checks of employees and applicants.
The facility failed to search the employee misconduct registry and nurse aide registry before hiring to determine if the individual is unemployable.
The facility failed to search the NAR and EMR annually.
The facility failed to obtain the required resident identifying information, such as each resident's full name and SSN at the time of admission.
The facility failed to either assess a resident or to develop, approve, sign, or follow a service plan within the allowable time.
The facility failed to procure food from acceptable sources, or failed to handle food, subject to spoilage, as required.
The facility failed to comply with Texas Food Establishment rules and local health ordinances and requirements.
The facility failed to ensure that all employees providing services were screened for tuberculosis within two weeks of employment and annually.
The facility failed to conduct and document a risk assessment for potential emergencies or disasters.
The facility failed to develop and maintain a written emergency preparedness and response plan based on its risk assessment under subsection (b) of this section and that is adequate to protect facility residents and staff in a disaster or emergency.
The facility's plan failed to document the contact information for the EMC for the area.
The facility's plan failed to include a process that ensures communication with the EMC.
The facility failed to notify the EMC of the facility's plan, take actions to coordinate with the EMC, and document communications with the EMC.
The facility failed to review the plan at least annually to reflect changes in information, within 30 days following a disaster, within 30 days after a drill, and within 30 days after a change in rule or policy.
The facility failed to document any reviews and updates made to the plan.
The facility failed to register with 2-1-1 Texas to assist the state in identifying persons who may need assistance in a disaster.
The facility failed to include a section addressing direction and control in the emergency preparedness and response plan.
The facility failed to provide a manual fire alarm pull within five feet of each exit door with a sign stating, "Pull to release door in emergency." (cited 2020-02-13)
The facility failed to ensure fire drills were conducted and documented to be in compliance with licensing standards for assisted living facilities. (cited 2020-02-13)
The facility failed to provide exit signs with emergency power. (cited 2020-02-13)
The facility failed to ensure an emergency generator was in compliance with licensing standards for assisted living facilities. (cited 2020-02-13)
The facility failed to provide an initial gas pressure test of the gas lines from the meter; and/or failed to ensure additional gas pressure tests were performed when gas service was interrupted; and/or that all gas heating systems were documented (cited 2020-02-13)
The facility failed to ensure the building and structure complied with other applicable chapters of the Life Safety Code, NFPA 101. (cited 2020-02-13)
Report Facts
Inspections on page: 2
Total citations: 24
Citation dates: 2
Enforcement actions: 0
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