Deficiencies (over last year)
Deficiencies (over last year)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
214% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 11
Date: Jul 13, 2021
Visit Reason
State-compiled facility profile showing multiple inspections including a comprehensive inspection in 2021 and life safety code inspections in 2019, with enforcement actions in 2025.
Findings
The 2021 inspection cited 10 violations of state standards with no health code violations found. The 2019 life safety inspections revealed multiple failures related to fire safety, emergency planning, and building compliance, all corrected. An enforcement action in 2025 cited failure to maintain an effective pest control program.
Deficiencies (11)
The facility failed to ensure the building and structure complied with Chapter 18, New Health Care Occupancies, of the Life Safety Code, 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 a written emergency plan that addresses the eight core functions of emergency management was provided.
The facility failed to ensure interior walls and/or ceilings were constructed with a material having at least a 20-minute fire rating, or at least 3/8 gypsum board.
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 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 provide a site and/or building free of fire, health, or physical hazards.
The facility failed to provide and/or maintain portable fire extinguishers in compliance with licensing standards for assisted living facilities and NFPA 10.
553.104(l) — The facility failed to have an ongoing and effective pest control program and to provide insect screens on operable windows.
Report Facts
Inspections on page: 2
Date range of inspections: 2019-04-16 to 2021-07-13
Total fines: 2450
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