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Source: Texas Health & Human Services Commission
Key Findings
An inspection on October 7, 2021, identified 34 Life Safety Code violations, primarily concerning fire safety systems, maintenance of electrical/heating systems, and deficiencies in the emergency preparedness and response plan. No enforcement actions were found in the provided report.
Life Safety Code (35 violations)
The facility failed to include a section addressing resource management in the emergency preparedness and response plan.
The facility failed to include a section addressing warning in the emergency preparedness and response plan.
The facility failed to register with 2-1-1 Texas to assist the state in identifying persons who may need assistance in a disaster.
The facility failed to provide safe waste containers in kitchens and hazardous areas.
The facility failed to maintain electrical, heating, and cooling systems so they worked safely.
The failed to provide safe waste containers in smoking areas.
The facility failed to ensure an attic was not used for storage.
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.
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.
The facility failed to have a complete fire safety plan for the protection of everyone in the facility in the event of a fire.
The facility failed to provide the required emergency preparedness and response plan training and conduct drills.
The facility failed to provide a resident or legally authorized agent with the name, address, and contact information for each receiving facility or pre-arranged evacuation destination identified by the facility.
The facility failed to have and enforce a smoking policy.
The facility failed to maintain outdoor areas in good condition and to keep outdoor areas free of fire or health hazards.
The receiving facility's plan failed to include procedures for accommodating a temporary emergency placement of one or more residents during a disaster or emergency.
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.
The facility failed to include a section addressing transportation in the emergency preparedness and response plan.
The facility failed to ensure equipment could be accessed to the facility could inspect, test, and service the equipment.
The facility failed to include a section addressing direction and control in the emergency preparedness and response plan.
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.
The facility failed to develop and maintain a written emergency preparedness and response plan based on its risk assessment under subsection (b) of this section and that is adequate to protect facility residents and staff in a disaster or emergency.
The facility failed to notify each resident, next of kin, or legally authorized representative how to register for evacuation assistance with 2-1-1 Texas.
The facility's emergency preparedness and response plan failed to address the eight core functions of emergency management.
The facility failed to provide the minimum levels of illumination required in the facility.
The facility failed to include a section addressing communication in the emergency preparedness and response plan.
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
The facility failed to keep floors in good condition and regularly cleaned.
The facility failed to include a section addressing health and medical needs in the emergency preparedness and response plan.
The facility's plan failed to include the location of a current list of the facility's resident population.
The facility failed to conduct required fire drills and document fire drills on the required form.
The facility failed to inspect, test, and maintain fire alarm system components.
The facility failed to inspect, test, and maintain fire sprinkler system components.
The facility failed to ensure resident room doors would latch in their frames.
The facility failed to notify the EMC of the facility's plan, take actions to coordinate with the EMC, and document communications with the EMC.
The facility's plan failed to include a process that ensures communication with the EMC.
Orchid Care Homes LLC
for profit
SIMON KOITHARA
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TX HHSC — View Official Record
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