Deficiencies (over last year)
Deficiencies (over last year)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
386% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Life Safety
Deficiencies: 17
Date: Jun 6, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 to 2024 with deficiency history including health code and life safety code violations.
Findings
The facility had multiple deficiencies across inspections including failure to follow service plan protocols, employee registry checks, and numerous life safety code violations related to emergency systems, fire safety equipment, and building code compliance. Most deficiencies were corrected within a month or a few months after the June 2024 inspection.
Deficiencies (17)
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 search the employee misconduct registry and nurse aide registry before hiring to determine if the individual is unemployable.
The facility failed to search the NAR and EMR annually.
The facility failed to test and maintain an emergency generator that provides power to emergency lighting.
The facility failed to notify HHSC in writing prior to the start of building rehabilitation.
The facility failed to ensure means of egress met the referenced codes and standards.
The facility failed to provide smoke detectors in the required locations.
The facility failed to provide a fire alarm control panel visible to facility staff or monitored by devices carried by facility staff, that indicated the location of a fire alarm event.
The facility failed to provide portable fire extinguishers that met the referenced codes and standards.
The facility failed to ensure flammable and combustible liquids were not stored in buildings used by residents.
The facility failed to provide the minimum levels of illumination required in the facility.
The facility failed to provide an approved outdoor area for the segregated unit.
The facility failed to provide proper locking devices.
The facility failed to ensure doors in the facility met the referenced codes and standards.
The facility failed to provide smoke compartmentation where required.
The facility failed to ensure portable fire extinguishers were mounted on hangers or brackets supplied with the fire extinguisher or mounted in a fire extinguisher cabinet, were protected from impact or dislodgement, and were mounted at the appropriate height based on the weight of the extinguisher.
The facility failed to ensure the building electrical system met the referenced codes and standards.
Report Facts
Inspections on page: 2
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