Rehoboth Assisted Living Facility, LLC

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

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

The facility failed to maintain outdoor areas in good condition and to keep outdoor areas free of fire or health hazards.

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

The facility failed to ensure flammable and combustible liquids were not stored in buildings used by residents.

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

The facility failed to check gas heating systems prior to the heating season and to maintain records of the those checks.

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

The facility's plan failed to document the contact information for the EMC for the area.

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

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

Life Safety CodeCited Nov 12, 2025Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

The facility failed to have and enforce a smoking policy.

Health VisitCited Dec 17, 2024Corrected —

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.

Health VisitCited Dec 17, 2024Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

The provider failed to properly post or disclose to prospective residents the facility's normal 24-hour staffing pattern.

Health VisitCited Dec 17, 2024Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

The facility failed to train all staff in emergency and evacuation procedures prior to their assuming any job responsibilities.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to have documented evidence that direct care staff had completed all required continuing education.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to keep current and complete personnel records

Health VisitCited Dec 17, 2024Corrected —

The facility failed to conduct criminal history checks of employees and applicants.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to search the employee misconduct registry and nurse aide registry before hiring to determine if the individual is unemployable.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to search the NAR and EMR annually.

Health VisitCited Dec 17, 2024Corrected —

The provider failed to have a written admission agreement between the facility and the resident explaining details concerning services and charges and that also included a statement concerning possible Medicare benefits.

Health VisitCited Dec 17, 2024Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

The facility failed to provide every resident with a copy of the Resident Bill of Rights.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to provide every resident's immediate family with the HHSC telephone hotline number to report suspected abuse, neglect, or exploitation and document that the family received it.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to ensure that a licensed person or a trained, authorized, and delegated person administered medications according to physician's orders.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to provide a locked area for all medications.

Health VisitCited Dec 17, 2024Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

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.

Health VisitCited Dec 17, 2024Corrected —

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

Health VisitCited Dec 17, 2024Corrected —

The facility failed to post the Provider Bill of Rights.

Health VisitCited Dec 17, 2024Corrected —

The provider failed to post the facility's normal 24- hour staffing patterns.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to post HHSC telephone hotline number to report suspected abuse, neglect, or exploitation.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to have staff sign a statement indicating an employee may be criminally liable for the failure to report abuse, neglect, or exploitation.

Health VisitCited Dec 17, 2024Corrected —

The facility's plan failed to document the contact information for the EMC for the area.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to register with 2-1-1 Texas to assist the state in identifying persons who may need assistance in a disaster.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to have documented evidence showing that it had explained and provided a copy of the disclosure statement to the resident, family, or responsible party prior to admitting a resident.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to provide written notice at the time of admission about advance directive policies to either a resident or to a resident's surrogate decision-maker.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to maintain in each resident's active clinical record a signed copy of the required form concerning Authorized Electronic Monitoring.

Health VisitCited Dec 17, 2024Corrected —

The facility failed to provide residents and residents' legally authorized representative with a copy of the plan upon admission, on request, and when a significant change to the plan is made.

Health VisitCited Dec 17, 2024Corrected —