Evergreen Assisted Living LLC

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

The facility failed to report incidents of abuse, neglect, or exploitation to HHSC's state office, or failed to follow its and its own internal policies regarding abuse, neglect, or exploitation.

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

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

The facility failed to implement, enforce or have written policies for the control of communicable diseases including tuberculosis (TB) screening and provision of a safe and sanitary environment for employees and residents.

The facility failed to have a refrigerator with a designated and locked storage area for medications requiring refrigeration.

The facility either failed to provide required counseling to residents who self-administer medications or failed to maintain a written counseling record.

The facility failed to provide a written contract with a fire alarm firm to perform inspections, testing, and system maintenance at least every six months.

The facility failed to ensure the required sprinkler system was inspected, tested, and maintained in compliance with NFPA 25.

The facility failed to provide an approved path of travel to a public throughway.

The facility failed to ensure compliance with smoking regulations in the licensing standards for assisted living facilities.

The facility failed to ensure all monthly and yearly extinguisher inspections were performed and/or documented; and/or that unserviceable extinguishers were replaced.

The facility failed to maintain a current printed copy of the plan in a location accessible to all staff, residents, and residents legally authorized representatives at all times.

The facility failed to comply with Chapter 33, Existing Residential Board and Care Occupancies.

The facility failed to provide an initial gas pressure test of the gas lines from the meter; and/or failed to ensure additional gas pressure tests were performed when gas service was interrupted; and/or that all gas heating systems were documented

The facility failed to ensure the building and structure complied with other applicable chapters of the Life Safety Code, NFPA 101.