Deficiencies (over last year)
Deficiencies (over last year)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
443% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 19
Date: Jul 15, 2021
Visit Reason
State-compiled facility profile showing multiple inspections from 2021 with deficiency history.
Findings
The facility had multiple violations across health and life safety codes during inspections in April and July 2021, including medication storage, food handling, emergency preparedness, fire safety, and building maintenance issues. All cited deficiencies were corrected within days to weeks after the inspections.
Deficiencies (19)
The facility failed to provide a locked area for all medications.
The facility failed to procure food from acceptable sources, or failed to handle food, subject to spoilage, as required.
The facility failed to include a section addressing transportation in the emergency preparedness and response plan.
The facility failed to ensure that locking devices on control doors released when a switch or button was activated at the monitoring station and at the main staff station.
The facility failed to comply with Chapter 19 of NFPA 101.
The facility failed to ensure fire drills were conducted and documented to be in compliance with licensing standards for assisted living facilities.
The facility failed to ensure an emergency generator was in compliance with licensing standards for assisted living facilities.
The facility failed to ensure the smoke detectors were to be tested for sensitivity as required. The facility failed to provide all required fire alarm documentation, including as-built installation drawings, operation and maintenance manuals, and a written sequence of operation, must be available for examination by DADS.
The facility failed to ensure the required sprinkler system was inspected, tested, and maintained in compliance with NFPA 25.
The facility failed to provide the required sprinkler system to meet NFPA 13.
The facility failed to provide operable windows or powered exhaust that is required for all odor-producing rooms.
The facility failed to ensure an annual inspection was conducted by the local fire marshal.
The facility failed to provide reasonable access and/or necessary equipment for maintenance, testing, and servicing of equipment.
The facility failed to implement procedures that assure safe and sanitary use and storage of oxygen.
The facility failed to ensure all monthly and yearly extinguisher inspections were performed and/or documented; and/or that unserviceable extinguishers were replaced.
The facility failed to provide and/or maintain a commercial range hood and exhaust system in compliance with NFPA 96.
The facility failed to ensure the fire alarm and smoke detection system was in compliance with licensing standards for assisted living facilities.
The facility failed to ensure the building was kept in good repair.
The facility failed to include a section addressing evacuation in the emergency preparedness and response plan.
Report Facts
Inspections on page: 2
Loading inspection reports...
