DEVINE ASSISTED LIVING

2025 · 58 cited

1. The facility failed to have sufficient staff to maintain order, safety, and cleanliness.

   Health VisitCited Jun 26, 2025Corrected —

2. The facility failed to document that staff were competent and trained prior to assuming their responsibilities.

   Health VisitCited Jun 26, 2025Corrected —

3. The facility failed to ensure that specific on-the-job training required for attendants in this type facility was completed in the required timeframe.

   Health VisitCited Jun 26, 2025Corrected —

4. The facility failed to ensure that each resident had a health examination by a physician performed within the required timeframe.

   Health VisitCited Jun 26, 2025Corrected —

5. The facility failed to either assess a resident or to develop, approve, sign, or follow a service plan within the allowable time.

   Health VisitCited Jun 26, 2025Corrected —

6. The facility failed to ensure that medications were administered according to physician's orders.

   Health VisitCited Jun 26, 2025Corrected —

7. 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).

   Health VisitCited Jun 26, 2025Corrected —

8. The facility failed to keep appropriate written records showing all prescribed medications and treatments that residents missed.

   Health VisitCited Jun 26, 2025Corrected —

9. The facility failed to keep discontinued medications separate from current medications or failed to meet requirements for appropriate disposal of discontinued medications.

   Health VisitCited Jun 26, 2025Corrected —

10. The facility failed to ensure that menus were prepared to provide a balanced and nutritious diet, that food was palatable and varied, or that menus were planned one week in advance, followed, posted and kept for 30-days, with variations documented.

    Health VisitCited Jun 26, 2025Corrected —

11. The facility failed to maintain the minimum four-day supply of staple foods and one-day supply of perishable foods on the premises.

    Health VisitCited Jun 26, 2025Corrected —

12. The facility failed to procure food from acceptable sources, or failed to handle food, subject to spoilage, as required.

    Health VisitCited Jun 26, 2025Corrected —

13. The facility failed to ensure that resident records included the required information and documentation.

    Health VisitCited Jun 26, 2025Corrected —

14. The facility failed to provide residents with access to their records or failed to safeguard records in a confidential manner.

    Health VisitCited Jun 26, 2025Corrected —

15. The facility failed to provide a 30-day written notice of transfer or discharge.

    Health VisitCited Jun 26, 2025Corrected —

16. The facility failed to provide a 30-day written notice with the effective date of the transfer or discharge.

    Health VisitCited Jun 26, 2025Corrected —

17. The facility failed to provide a 30-day written notice of transfer or discharge that included the location of transfer.

    Health VisitCited Jun 26, 2025Corrected —

18. The facility failed to provide a 30-day written notice of transfer or discharge that included appeal rights.

    Health VisitCited Jun 26, 2025Corrected —

19. The facility failed to post a copy of the most recent inspection report.

    Health VisitCited Jun 26, 2025Corrected —

20. The facility's plan failed to include the location of a current list of the facility's resident population.

    Health VisitCited Jun 26, 2025Corrected —

21. The facility manager and designee failed to enroll in an emergency communication system in accordance with instructions from HHSC.

    Health VisitCited Jun 26, 2025Corrected —

22. The facility failed to ensure that all full-time attendants were at least 18 years old or high school graduates; or that a qualified attendant was present at all times that residents were in the facility.

    Health VisitCited Jun 26, 2025Corrected —

23. The facility failed to have a complete fire safety plan for the protection of everyone in the facility in the event of a fire.

    Health VisitCited Jun 26, 2025Corrected —

24. The facility failed to conduct required fire drills and document fire drills on the required form.

    Health VisitCited Jun 26, 2025Corrected —

25. The facility failed to have and enforce a smoking policy.

    Health VisitCited Jun 26, 2025Corrected —

26. The failed to provide safe waste containers in smoking areas.

    Health VisitCited Jun 26, 2025Corrected —

27. The facility failed to ensure at least one window in each bedroom in a facility without fire sprinklers met the minimum requirements to use the window as a means of escape.

    Health VisitCited Jun 26, 2025Corrected —

28. The facility failed to provide the minimum required number of bathtubs or showers.

    Health VisitCited Jun 26, 2025Corrected —

29. The facility failed to provide towels, soap and toilet tissue for individual resident use.

    Health VisitCited Jun 26, 2025Corrected —

30. The facility failed to provide heating and cooling for resident comfort that ensured air temperatures between 68 and 82 degrees F in resident-use areas.

    Health VisitCited Jun 26, 2025Corrected —

31. The facility failed to provide a telephone for use by residents and staff with emergency telephone numbers posted at or near the telephone.

    Health VisitCited Jun 26, 2025Corrected —

32. The facility failed to designate a manager in writing or did not have proof of the manager's qualifications.

    Health VisitCited Jun 26, 2025Corrected —

33. The facility failed to have evidence showing that the manager completed the required 12 hours of annual continuing education.

    Health VisitCited Jun 26, 2025Corrected —

34. The facility failed to develop and implement required staffing policies that met state standards.

    Health VisitCited Jun 26, 2025Corrected —

35. The facility failed to have sufficient staff to assure that each resident would receive the kind and amount of supervision and care required to meet basic needs.

    Health VisitCited Jun 26, 2025Corrected —

36. The facility failed to have sufficient staff to ensure safe evacuation of the facility in the event of emergency.

    Health VisitCited Jun 26, 2025Corrected —

37. The provider failed to ensure that night staff was immediately available in a small facility, or immediately available and awake in a large facility.

    Health VisitCited Jun 26, 2025Corrected —

38. The facility failed to keep floors in good condition and regularly cleaned.

    Life Safety CodeCited Jun 6, 2025Corrected —

39. The facility failed to keep walls and ceilings in good condition.

    Life Safety CodeCited Jun 6, 2025Corrected —

40. The facility failed to have an ongoing and effective pest control program and to provide insect screens on operable windows.

    Life Safety CodeCited Jun 6, 2025Corrected —

41. The facility failed to ensure resident room doors in a building that does not have fire sprinklers were solid doors that were at least 1-3/4 inches thick or had an opening protection rating of at least 20 minutes, that the doors were self-closing or automatic-closing, and that the doors would latch in their frames.

    Life Safety CodeCited Jun 6, 2025Corrected —

42. The facility failed to ensure the building electrical system met the referenced codes and standards.

    Life Safety CodeCited Jun 6, 2025Corrected —

43. The facility failed to provide the minimum levels of illumination required in the facility.

    Life Safety CodeCited Jun 6, 2025Corrected —

44. The facility failed to include a section addressing warning in the emergency preparedness and response plan.

    Life Safety CodeCited Jun 6, 2025Corrected —

45. The facility failed to correct a site or building condition that was a fire, health, or physical hazard.

    Life Safety CodeCited Jun 6, 2025Corrected —

46. The facility failed to obtain an inspection by the fire marshal every year and to keep documentation showing the outcome of the last inspection.

    Life Safety CodeCited Jun 6, 2025Corrected —

47. The facility failed to train staff in the use of fire extinguishers, failed to inspect and maintain fire extinguishers, and failed to keep records of inspection and maintenance of fire extinguishers.

    Life Safety CodeCited Jun 6, 2025Corrected —

48. The facility failed to obtain pressure tests of gas piping in the facility.

    Life Safety CodeCited Jun 6, 2025Corrected —

49. The facility failed to provide the required emergency preparedness and response plan training and conduct drills.

    Life Safety CodeCited Jun 6, 2025Corrected —

50. The facility failed to have a program to inspect, test, and maintain the fire alarm system and keep records of inspection, testing, and maintenance of the fire alarm system.

    Life Safety CodeCited Jun 6, 2025Corrected —

51. The facility failed to keep documentation about the fire alarm system onsite at the facility.

    Life Safety CodeCited Jun 6, 2025Corrected —

52. The facility failed to provide a manual fire alarm system that met the referenced codes and standards.

    Life Safety CodeCited Jun 6, 2025Corrected —

53. The facility failed to ensure means of escape met the referenced codes and standards.

    Life Safety CodeCited Jun 6, 2025Corrected —

54. The facility failed to conduct and document a risk assessment for potential emergencies or disasters.

    Life Safety CodeCited Jun 6, 2025Corrected —

55. 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.

    Life Safety CodeCited Jun 6, 2025Corrected —

56. The facility failed to include a section addressing transportation in the emergency preparedness and response plan.

    Life Safety CodeCited Jun 6, 2025Corrected —

57. The facility failed to have and enforce a smoking policy.

    Life Safety CodeCited Jun 6, 2025Corrected —

58. The facility failed to maintain electrical, heating, and cooling systems so they worked safely.

    Life Safety CodeCited Jun 6, 2025Corrected —