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: May 7, 2024
Visit Reason
State-compiled facility profile showing multiple inspections including a recent comprehensive inspection on May 7, 2024, with deficiency history and life safety code findings.
Findings
The most recent inspection cited 13 violations of state standards with no health code violations found. Previous life safety code inspections from January 28, 2021, showed multiple deficiencies related to emergency preparedness, fire safety, and building compliance, all corrected by early 2021.
Deficiencies (13)
The facility failed to comply with Chapter 19 of NFPA 101.
The facility failed to ensure the building and structure complied with other applicable chapters of the Life Safety Code, NFPA 101.
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 ensure the installation of the smoke detection system complied with applicable requirements.
The facility failed to provide a site and/or building free of fire, health, or physical hazards.
The facility's plan failed to document the contact information for the EMC for the area.
The facility failed to notify the EMC of the facility's plan, take actions to coordinate with the EMC, and document communications with the EMC.
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 include a section addressing communication in the emergency preparedness and response plan.
The facility failed to provide the required sprinkler system to meet NFPA 13.
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: 13
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