Inspection Report
Life Safety
Deficiencies: 10
Jun 4, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with applicable fire safety codes and regulations.
Findings
The facility failed to maintain several life safety requirements including improper hot water temperature, lack of documentation for semi-annual waterflow alarm testing, missing evidence of 5-year internal investigations and monthly inspections of fire suppression systems, incomplete UL hood suppression and cleaning inspections, failure to conduct monthly emergency light/exit signage testing, inoperable emergency light units, improper storage of oxygen cylinders, missing documentation for fuel-fired heating system inspections, and failure to conduct required fire drills at night and bi-monthly intervals.
Deficiencies (10)
| Description |
|---|
| Hot water temperature in the men's common area restroom was 128°F, exceeding the required maximum of 120°F. |
| Facility could not provide documentation of semi-annual vane type waterflow alarm device testing as required. |
| Annual fire alarm documentation did not list locations of devices tested; missing 5-year internal investigation and pressure gauge recalibration documentation for fire suppression systems; failed monthly inspections of pressure gauges for wet and dry systems for multiple months. |
| Missing documentation for one of two semi-annual UL hood suppression system inspections; last documented inspection was 4/18/25 with no prior documentation. |
| Missing documentation for two semi-annual UL hood cleaning inspections; last documented cleaning was January 20, 2024. |
| Facility last conducted annual emergency light testing for 90 minutes in January 2024 but failed monthly emergency light/exit signage testing from January through March 2025. |
| Emergency light units located in stairwell across from room #101 and on both sides of the salon were inoperable. |
| Two E-size oxygen cylinders were stored directly on the floor and one on top of a file cabinet, not secured in proper carts or racks as required. |
| Facility lacked documentation for annual inspection of fuel-fired heating systems covering rooftop furnace units. |
| Facility failed to conduct at least six fire drills annually on a bi-monthly basis including two at night during normal sleeping hours; no drills conducted between July 2024 and April 2025, and none during night hours since April 2024. |
Report Facts
Temperature: 128
Date: Apr 18, 2025
Date: Jan 20, 2024
Duration: 90
Fire drills required: 6
Fire drills conducted: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Corrie | Administrator | Named as facility administrator |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader conducting the inspection |
Inspection Report
Original Licensing
Deficiencies: 8
Nov 1, 2024
Visit Reason
The inspection was conducted as a health care initial licensure inspection combined with a complaint investigation.
Findings
The facility was found deficient in multiple areas including incomplete criminal background checks for employees, failure to provide written responses to complaints within 30 days, lack of current medication orders for residents, medication availability issues, improper medication destruction documentation, inadequate resident service agreements, failure to document investigations after resident incidents, and inconsistent offering of snacks and fluids to residents.
Complaint Details
The complaint investigation found that the facility failed to provide written responses to complaints within 30 days and had other deficiencies related to medication orders and resident care.
Deficiencies (8)
| Description |
|---|
| Two of ten employees did not have a Department Criminal History and Background Check; one employee with pending background check worked unsupervised. |
| Facility did not provide written responses to complainants within 30 days as required. |
| Four of seven sampled residents' records lacked current, signed medication orders. |
| Residents' as-needed and scheduled medications were not consistently available in the medication cart. |
| No witness present for all resident medication destruction and method of destruction was not documented. |
| Residents' Negotiated Service Agreements did not clearly reflect needs or describe services to be provided. |
| Administrator did not document investigations or corrective actions after resident incidents including falls. |
| Residents were not consistently offered snacks and fluids between meals and at bedtime. |
Report Facts
Employees without background check: 2
Sampled residents with missing medication orders: 4
Medication patch not available: 7
Medication destruction log signatures: 1
Resident falls: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Corrie | Administrator | Confirmed that Department Criminal History and Background Checks were not completed and stated verbal responses were given to complainants. |
| Mina Ramirez | Survey Team Leader | Led the health care initial licensure and complaint investigation survey. |
| Resident Care Coordinator | RCC | Stated she destroyed all medications alone unless it was a narcotic substance. |
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