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: Feb 28, 2022
Visit Reason
State-compiled facility profile showing multiple inspections from 2021-2022 with deficiency history related to health and life safety codes.
Findings
The facility had 15 violations cited during the most recent comprehensive inspection on February 28, 2022, primarily related to life safety code deficiencies including fire drills, fire alarm and sprinkler system maintenance, and building condition issues. A prior inspection in 2021 cited a failure to conduct required annual searches of NAR and EMR.
Deficiencies (14)
The facility failed to search the NAR and EMR annually.
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 inspect, test, and maintain fire alarm system components.
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 inspect, test, and maintain fire sprinkler system components.
The facility failed to keep walls and ceilings in good condition.
The facility failed to store oxygen provided by the facility 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 test and maintain an emergency generator that provides power to emergency lighting.
The facility failed to provide smoke compartmentation where required.
The facility failed to ensure doors in the facility met the referenced codes and standards.
The facility failed to protect hazardous areas as required by the referenced codes and standards.
The facility failed to protect cooking operations according to the Life Safety Code.
Report Facts
Inspections on page: 2
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