Deficiencies (over last year)
Deficiencies (over last year)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
300% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 14
Date: Jul 5, 2022
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 with deficiency history.
Findings
The facility had 16 violations cited during the most recent comprehensive inspection in July 2022, with multiple life safety code deficiencies related to fire drills, fire alarm and sprinkler system maintenance, building hazards, and emergency preparedness. All cited deficiencies from the June 2022 life safety inspection were corrected by July 24, 2022, while the July 2022 health code violations remain pending.
Deficiencies (14)
The facility failed to conduct required fire drills and document fire drills on the required form.
The facility failed to have a program to inspect, test, and maintain the fire alarm system and keep records of inspection, testing, and maintenance of the fire alarm system.
The facility failed to have a program to inspect, test, and maintain the fire sprinkler system and keep records of inspection, testing, and maintenance of the fire sprinkler system.
The facility failed to keep buildings clean and free of hazards.
The facility failed to have policies about storing oxygen owned by residents in a safe and sanitary manner.
The facility failed to check gas heating systems prior to the heating season and to maintain records of the those checks.
The facility failed to ensure doors in the facility met the referenced codes and standards.
The facility failed to ensure resident room doors would latch in their frames.
The facility failed to ensure doors to resident rooms and living units could be closed by the occupants.
The facility failed to protect commercial cooking equipment according to the standard for ventilation control and fire protection of commercial cooking operations.
The facility failed to conduct and document a risk assessment for potential emergencies or disasters.
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 include a section addressing communication in the emergency preparedness and response plan.
The facility failed to include a section addressing evacuation in the emergency preparedness and response plan.
Report Facts
Inspections on page: 2
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