Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Life Safety
Deficiencies: 8
Jun 5, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to evaluate compliance with fire and life safety codes and standards.
Findings
The facility failed to meet multiple fire and life safety standards including inadequate documentation of fire suppression system inspections, missing monthly inspections of portable fire extinguishers, failure to conduct required emergency lighting tests, incomplete fire alarm inspection reports, prohibited electrical equipment usage, and insufficient fire drill frequency.
Deficiencies (8)
| Description |
|---|
| Designated smoking area was not clearly marked and policy did not state this area as designated. |
| Facility could not provide documentation of smoke/fire dampers testing/inspection within last 4 years; some dampers failed to close upon alarm activation. |
| No documentation of internal investigation of fire suppression piping, pressure gauge replacement/calibration, or check valve investigation within last 5 years. |
| No documentation for annual/semi-annual inspection and testing of fire suppression wet systems in multiple buildings. |
| Portable fire extinguishers missing monthly inspection for April 2025 in all buildings. |
| Life Safety Code standards not met for buildings housing 3-16 residents: incomplete fire alarm inspection reports, missing monthly wet system pressure gauge checks, failure to conduct monthly emergency lighting tests. |
| Life Safety Code standards not met for buildings housing 17 or more residents: incomplete fire alarm inspection reports, missing monthly wet/dry system pressure gauge checks, no air leakage test for dry suppression system, failure to conduct monthly emergency lighting tests, incomplete hood suppression inspections and cleaning, stored items too close to sprinkler pendant, prohibited multi-plug adapters and RPT use, incomplete fuel-fired heating inspections. |
| Facility failed to conduct fire drills bi-monthly with required number during normal sleeping hours; last drills conducted December 31, 2024 and February 23, 2024 for building #2. |
Report Facts
Fire extinguisher monthly inspections missing: 1
Fire drills conducted: 1
Fire drills conducted for building #2: 1
Fire suppression system air compressor cycle: 15
Fire suppression system air compressor cycle: 20
Fire drills required bi-monthly: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Crowley | Administrator | Named as facility administrator in report header |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader conducting fire life safety and sanitation licensure survey |
Inspection Report
Original Licensing
Deficiencies: 8
Nov 15, 2024
Visit Reason
The inspection was conducted as a health care initial licensure inspection combined with a complaint investigation.
Findings
The facility was found to have multiple deficiencies including unsecured toxic chemicals accessible to cognitively impaired residents, failure to monitor and document medication refrigerator temperatures, unavailability of some residents' as-needed medications, outdated negotiated service agreements not reflecting residents' current health status, menus not posted in memory care buildings, insufficient staffing in detached buildings, and inadequate staff orientation and specialized training following a change of ownership.
Complaint Details
The inspection included a complaint investigation component as indicated by the survey type.
Deficiencies (8)
| Description |
|---|
| The facility did not secure cleaning chemicals in the laundry room accessible to cognitively impaired residents. |
| Medication refrigerator temperatures were not monitored and documented daily in multiple buildings. |
| Not all residents' as-needed (PRN) medications were available in the medication cart. |
| Negotiated Service Agreements (NSAs) were not updated to reflect significant changes in residents' health and physical status. |
| Facility menus were not posted in common areas of memory care buildings for residents to view. |
| The facility did not ensure sufficient staffing in all buildings to have one staff member present at all times. |
| Four staff retained through change of ownership did not have 16 hours of job-related orientation and infection control training. |
| Four staff retained through change of ownership did not have specialized training for residents with dementia, mental illness, developmental disabilities, or traumatic brain injury. |
Report Facts
Days medication refrigerator temperatures not documented: 10
Days medication refrigerator temperatures not documented: 26
Days medication refrigerator temperatures not documented: 30
Days medication refrigerator temperatures not documented: 4
Staff without required orientation training: 4
Staff without specialized training: 4
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