Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Inspection Report
Life Safety
Deficiencies: 4
Sep 16, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at the Emerald Heights residential care facility to assess compliance with fire safety regulations.
Findings
The inspection identified multiple violations including unsecured kitchen gas stove, propped open fire rated doors, and lack of documentation for sprinkler system tests and fire department connections.
Deficiencies (4)
| Description |
|---|
| Kitchen gas stove was not tethered to the wall. |
| Fire rated doors were propped open using various items. |
| Facility unable to provide documentation on 5-year internal pipe test, 3-year dry system full flow test, annual trip test, and annual forward flow test for sprinkler systems. |
| Facility unable to provide documentation on 5-year FDC Hydro Test for fire department connections. |
Report Facts
Next inspection scheduled date: Oct 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed the inspection report |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Aug 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding physical environment, quality of care/treatment, financial exploitation, and resident/patient/client rights at Emerald Heights Assisted Living Facility.
Findings
The investigation found that the facility failed to ensure apartment entry doors were safely operated, resulting in resident injuries and difficulty entering/exiting apartments. Other allegations such as failure to install a shower barrier, charging for durable medical equipment, and mailbox accessibility were found to have insufficient evidence for violations. The facility was cited for failure to maintain safe apartment entry doors.
Complaint Details
The complaint investigation was based on allegations of unsafe apartment entry doors, quality of care, financial exploitation related to durable medical equipment charges, and resident rights violations including mailbox accessibility. The facility was found to have failed provider practice regarding the apartment doors, but insufficient evidence was found for other allegations.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure apartment entry doors were safely operated, causing injuries to residents. |
Report Facts
Total residents: 50
Resident sample size: 7
Closed records sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Yip | ALF Licensor | Investigator and on-site verification staff |
| Thomas Forkgen | ALF Licensor | On-site verification staff |
| James Sherman | Field Manager | Signed follow-up inspection letter |
| Staff P | Licensed Practical Nurse, Assisted Living Director | Interviewed regarding monitoring of Resident 4's blood sugar and notification of healthcare provider |
| Staff Q | Executive Director | Interviewed regarding residents' concerns about apartment entry doors |
Inspection Report
Life Safety
Deficiencies: 5
Mar 17, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at Emerald Heights on 03/17/2025 to assess compliance with fire protection codes and regulations.
Findings
The facility was found to have multiple fire safety deficiencies including open electrical terminations, fire-rate construction inspection needs, door operation issues with double doors not latching, commercial cooking system violations, and a water drinking station exceeding allowed projection. The facility was disapproved due to these violations and required to correct all deficiencies upon re-inspection.
Deficiencies (5)
| Description |
|---|
| Open wires found above room 217 coming out of flex tubing. |
| Facility needs to perform an inspection regarding Fire-Rate-Construction to determine UL fire blocking. |
| Double doors found in corridor by room 116 will not latch. |
| Deep fryer found next to open flame broiler without required separation. |
| 2nd floor water drinking station exceeding allowed 4 inch horizontal projection. |
Report Facts
Inspection date: Mar 17, 2025
Next inspection scheduled: Apr 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Conducted the fire safety inspection and signed the report |
| Jamilyn Bloodworth | Administrator | Facility Administrator named in the report |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 3
May 21, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 05/21/2024 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets the Assisted Living Facility licensing requirements. The prior deficiencies related to infection control, Medicaid acceptance policy, and tuberculosis screening were corrected.
Deficiencies (3)
| Description |
|---|
| Failure to implement infection control policies and requirements to protect 38 residents from an infectious illness. |
| Failure to provide 38 residents with a copy of the facility's policy for acceptance of Medicaid as a payment source. |
| Failure to ensure 3 of 6 staff were screened for tuberculosis within three days of employment. |
Report Facts
Residents present during inspection: 38
Residents reviewed: 9
Staff not screened for tuberculosis: 3
Total staff requiring tuberculosis screening: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Garrett | LTC Licensor | Department staff who conducted the on-site verification |
| Claudia Allis | Community Complaint Investigator | Department staff who conducted the on-site verification |
| Laurie Anderson | Field Manager | Signed the Statement of Deficiencies and correspondence |
| Jayne Hill | Field Manager | Signed the follow-up inspection letter |
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