Deficiencies (over last year)
Deficiencies (over last year)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
271% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 13
Date: Dec 15, 2021
Visit Reason
State-compiled facility profile showing multiple inspections including a comprehensive inspection in 2021 and life safety inspections in 2020 with enforcement actions.
Findings
The facility had 13 violations cited in the December 2021 inspection and multiple life safety code violations in February 2020, all corrected. An enforcement action in 2025 involved a penalty related to fire safety plan deficiencies.
Deficiencies (13)
The facility failed to ensure that locking devices on exit doors released when the fire alarm or sprinkler system were activated.
The facility failed to ensure that locking devices on exit doors released when a switch or button was activated at the monitoring station and at the main staff station.
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."
The facility failed to comply with Chapter 19 of NFPA 101.
The facility failed to provide lighting levels in compliance with licensing standards for assisted living facilities.
The facility failed to provide a written contract with a fire alarm firm to perform inspections, testing, and system maintenance at least every six months.
The facility failed to ensure the smoke detectors were tested for sensitivity as required and failed to provide all required fire alarm documentation including installation drawings and manuals.
The facility failed to ensure the required sprinkler system was inspected, tested, and maintained in compliance with NFPA 25.
The facility failed to provide operable windows or powered exhaust required for all odor-producing rooms.
The facility failed to ensure the building was kept in good repair.
The facility failed to provide an initial gas pressure test of the gas lines from the meter and/or additional tests when gas service was interrupted and failed to document all gas heating systems.
The facility failed to provide and/or maintain a commercial range hood and exhaust system in compliance with NFPA 96.
The facility failed to have a complete fire safety plan for the protection of everyone in the facility in the event of a fire.
Report Facts
Inspections on page: 2
Total fines: 3750
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