West Lake Assisted Living

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 keep documentation about the fire sprinkler system onsite at the facility.

The facility failed to provide portable fire extinguishers that met the referenced codes and standards.

The facility failed to inspect, test, and maintain fire alarm system components.

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 keep buildings clean and free of hazards.

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

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

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

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

The facility's emergency preparedness and response plan failed to address the eight core functions of emergency management.

The failed to provide safe waste containers in smoking areas.

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 ensure equipment using natural gas or propane met the referenced codes and standards.

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

The facility failed to document any reviews and updates made to the plan.

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

The facility failed to ensure the sensitivity of smoke detectors was checked according to NFPA 72.

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 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 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.

The facility failed to obtain documentation from the local Authorities Having Jurisdiction (AHJ) that show that the facility meets local requirements.

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 correct a site or building condition that was a fire, health, or physical hazard.

The facility failed to ensure resident room doors would latch in their frames.

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

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

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

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

The facility failed to submit an acceptable plan of correction to the regional director within the required time period.

The facility failed to inspect, test, and maintain carbon monoxide detection system components.

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 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 conduct required fire drills and document fire drills on the required form.

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 storage areas organized and free of obstructions.

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 failed to keep walls and ceilings in good condition.

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

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

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 keep floors in good condition and regularly cleaned.

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

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

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 ensure doors to resident rooms and living units could be closed by the occupants.

The facility failed to have and enforce a smoking policy.

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

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

The facility's plan failed to include a process that ensures communication with the EMC.

The facility failed to provide sufficient storage space.

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

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

The facility failed to ensure doors in the facility met the referenced codes and standards.

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