Inspection Report — Oct 23, 2025
Citations: 13
Date: Oct 23, 2025
Visit Reason
State-compiled facility profile showing 13 citations from 2 inspection dates in 2025 with deficiency history.
Findings
The facility was cited for 13 violations across two inspection dates in 2025, including one health code citation and twelve life safety code citations. All citations are currently pending correction with no enforcement actions recorded.
Citations (13)
The facility failed to keep a copy of the initial or annual search of the NAR and EMR in the employee's personnel file.
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 obtain an inspection by the fire marshal every year and to keep documentation showing the outcome of the last inspection.
The facility failed to conduct required fire drills and document fire drills on the required form.
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 ensure the sensitivity of smoke detectors was checked according to NFPA 72.
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 maintain electrical, heating, and cooling systems so they worked safely.
The facility failed to keep buildings clean and free of hazards.
The facility failed to ensure the building structure was sheathed to provide a 20-minute fire resistance rating or was constructed to meet the construction requirements for a nursing home.
The facility failed to provide required emergency lighting.
The facility failed to provide portable fire extinguishers that met the referenced codes and standards.
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.
Report Facts
Inspections on page: 2
Total citations: 13
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