Deficiencies (over last year)
Deficiencies (over last year)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
386% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 17
Date: Mar 18, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 to 2024 with deficiency history.
Findings
Multiple inspections identified violations including failure to conduct employee background checks, improper medication handling, and numerous life safety code violations related to fire sprinkler systems, building maintenance, and emergency preparedness. Most deficiencies were corrected within specified timeframes.
Deficiencies (17)
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 keep discontinued medications separate from current medications or failed to meet requirements for appropriate disposal of discontinued medications.
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 inspect, test, and maintain fire sprinkler system components.
The facility failed to keep buildings clean and free of hazards.
The facility failed to ensure an attic was not used for storage.
The facility failed to have an ongoing and effective pest control program and to provide insect screens on operable windows.
The facility failed to provide a fire sprinkler system that met the referenced codes and standards.
The facility failed to ensure the building electrical system met the references codes and standards.
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 provide the required emergency preparedness and response plan training and conduct drills.
The facility failed to provide a monitoring station (or failed to provide details about the monitoring station) for the segregated unit.
The facility failed to provide an approved outdoor area for the segregated unit.
The facility failed to provide proper locking devices.
The failed to provide safe waste containers in smoking areas.
The facility did not use its state-issued facility identification number in all advertisements.
Report Facts
Inspections on page: 3
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