Inspection Report
Follow-Up
Census: 56
Deficiencies: 7
Jul 14, 2025
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies at FAIRWINDS - BRIGHTON COURT Assisted Living Facility.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to assessments, family assistance with medications, staff training, tuberculosis testing, medication availability, nurse delegation, and negotiated service agreements were corrected.
Deficiencies (7)
| Description |
|---|
| Failed to use an appropriate tool to annually assess dementia-related special needs for 1 sampled resident. |
| Failed to ensure a written plan for family assistance with medications for 2 sampled residents. |
| Failed to ensure 2 of 3 sampled staff met long-term care worker training requirements including mental health specialty training and continuing education. |
| Failed to ensure 1 of 3 sampled staff completed required tuberculosis screening test within three days of hire. |
| Failed to obtain prescribed medications in a timely manner for 1 of 2 sampled residents. |
| Failed to follow nurse delegation criteria for 1 of 2 sampled residents, resulting in unqualified staff administering medications without proper delegation or training. |
| Failed to develop and document negotiated service agreements addressing care needs and alternate plans for 2 sampled residents. |
Report Facts
Residents present during inspection: 56
Sampled residents for review: 8
Sampled residents for deficiencies: 3
Sampled staff members: 3
Days medication unavailable: 8
Days medication unavailable: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Caregiver | Failed to complete tuberculosis screening test within three days of hire |
| Staff B | Resident Assistant/Caregiver | Did not complete mental health specialty training within 120 days of hire |
| Staff D | Resident Assistant/Caregiver | Did not complete required 12 hours continuing education between birthdates |
| Staff F | General Manager/Administrator | Confirmed deficiencies and lack of training or testing compliance |
| Staff G | Registered Nurse/Health and Wellness Nurse | Confirmed lack of nurse delegation and medication availability documentation |
| Staff H | Resident Assistant | Administered medications without nurse delegation |
| Staff I | Resident Assistant | Administered medications without nurse delegation |
| Staff J | Resident Assistant | Administered medications without nurse delegation |
Inspection Report
Follow-Up
Census: 50
Deficiencies: 0
Jan 19, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to staff training, tuberculosis testing, preadmission assessments, and full assessment topics were corrected or addressed with plans of correction.
Report Facts
Sample size for review: 8
Residents at risk: 13
Staff members required to complete tuberculosis testing: 6
Residents at risk from incomplete tuberculosis testing: 50
Residents sampled for pre-admission assessment: 3
Residents at risk from incomplete pre-admission assessment: 8
Residents sampled for full assessment: 4
Residents at risk from incomplete full assessment: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Faith Le | NCI | Department staff who did the on-site verification |
| Jamie Singer | Field Manager | Signed the follow-up inspection letter and plan of correction documents |
| Jackie Raquel Hall | Administrator (or Representative) | Signed multiple Plan/Attestation Statements for correction of deficiencies |
| Erin Steinbrenner | Nursing Consultant Institutional | Department staff who inspected the Assisted Living Facility |
| Staff G | Office Manager | Confirmed staff training deficiencies and tuberculosis testing status in interviews |
| Staff C | Resident Assistant | Named in training deficiency for lack of specialized dementia and mental health training |
| Staff D | Resident Assistant | Named in training deficiency for lack of specialized dementia and mental health training |
| Staff E | Resident Assistant | Named in training deficiency for lack of specialized dementia and mental health training |
| Staff B | Resident Assistant | Named in tuberculosis testing deficiency for incomplete TST testing |
| Staff I | Health and Wellness Manager | Confirmed missing pre-admission assessment and full assessment during interviews |
Inspection Report
Life Safety
Deficiencies: 7
Oct 26, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Fairwinds Brighton Court residential care facility.
Findings
The inspection found that all violations noted during previous related inspections have been corrected. Prior inspections documented multiple fire door operation issues, sprinkler head age concerns, lack of documentation for monthly smoke alarm testing, fire department connection testing, and an exit light not functioning.
Deficiencies (7)
| Description |
|---|
| Second floor fire door by room 252 (door number 37) did not close properly and was hanging up on the carpet. |
| Fire door on first floor to south section of the building by the mailboxes was not closing properly. |
| Hallway fire door to north wing on first floor by the general manager's office did not close properly; door coordinator appeared malfunctioned. |
| Sprinkler heads in kitchen cooler and freezer were more than 5 years old and require replacement per NFPA 25 standards. |
| Facility unable to provide documentation for monthly single station smoke alarm testing. |
| Facility unable to provide documentation that the Fire Department Connection has been hydrostatically tested every 5 years as required. |
| Exit light in hall by room 299 was not staying on. |
Report Facts
Inspection date: Oct 26, 2023
Inspection date: Sep 13, 2023
Inspection date: Aug 1, 2023
Fire door number: 37
Fire door number: 53
Fire door number: 35
NFPA sprinkler replacement interval: 5
Fire department connection hydrostatic test interval (years): 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Regua-Hall | General Manager | Named as owner or authorized representative signing inspection documents |
| Jesse Ward | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Travis Molenda | Plant Operations Supervisor | Named as owner or authorized representative signing inspection documents on 08/01/2023 inspection |
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