Deficiencies (over last year)
Deficiencies (over last year)
24 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
586% worse than Texas average
Texas average: 3.5 deficiencies/year
Deficiencies per year
24
18
12
6
0
Inspection Report
Deficiencies: 24
Date: Jun 18, 2024
Visit Reason
State-compiled facility profile showing multiple inspections including a comprehensive inspection on June 18, 2024, with deficiency history and life safety code findings.
Findings
The facility had 24 violations cited during the June 18, 2024 inspection related to health code deficiencies including food preparation, emergency planning, and posting required notices. Previous life safety code violations from 2019 involved fire safety, emergency generator compliance, and sprinkler system maintenance.
Deficiencies (24)
The facility failed to prepare food according to established food preparation practices and safety techniques.
The facility failed to conduct and document a risk assessment for potential emergencies or disasters.
The facility failed to maintain a current printed copy of the plan in a location accessible to all staff, residents, and residents legally authorized representatives.
The facility failed to either assess a resident or to develop, approve, sign, or follow a service plan within the allowable time.
The facility failed to post an HHSC sign that specifies how complaints may be filed with HHSC.
The facility failed to post an HHSC notice that states inspection reports are available at the facility for public inspection and provides a toll-free telephone number for information.
The facility failed to post a copy of the most recent inspection report.
The facility failed to post the Provider Bill of Rights.
The facility failed to post the telephone number of the managing local ombudsman and the Ombudsman Program.
The facility failed to post HHSC telephone hotline number to report suspected abuse, neglect, or exploitation.
The facility's plan failed to include the location of a current list of the facility's resident population.
The facility failed to list each resident's medications on a specific medication profile record documenting the required medication details (e.g., strength and dosage).
The facility either failed to provide required counseling to residents who self-administer medications or failed to maintain a written counseling record.
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 hazardous areas were constructed in compliance with licensing standards for assisted living facilities, and/or that volatile materials were not stored in the facility.
The facility failed to ensure an emergency generator was in compliance with licensing standards for assisted living facilities.
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 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 to be 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 ensure an annual inspection was conducted by the local fire marshal.
The facility failed to ensure lighting levels were in compliance with licensing standards for assisted living facilities and the Illumination Engineering Society of North America.
The facility failed to provide and/or maintain a commercial range hood and exhaust system in compliance with NFPA 96.
Report Facts
Inspections on page: 2
Violations cited: 24
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