Inspection Report
Follow-Up
Deficiencies: 0
May 9, 2025
Visit Reason
An off-site follow-up survey was initiated and concluded to verify correction of previously identified deficiencies.
Findings
The facility was determined to have corrected their deficiencies as alleged based on the implementation of an acceptable Plan of Correction.
Inspection Report
Annual Inspection
Census: 85
Capacity: 111
Deficiencies: 10
Apr 2, 2025
Visit Reason
Annual Life Safety Recertification Survey conducted to assess compliance with Medicare and Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency lighting testing, exit signage, kitchen hood extinguishing system maintenance, smoke barrier integrity, electrical safety, fire drills, fire door inspections, portable space heater use, food safety, and infection prevention and control practices.
Severity Breakdown
SS=D: 5
SS=E: 3
SS=F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide documentation for monthly 30-second and annual 90-minute emergency battery lighting testing. | SS=D |
| Failed to install 'Not an Exit' signage on an exterior door leading to a courtyard. | SS=D |
| Failed to maintain kitchen hood extinguishing system and complete semi-annual inspections. | SS=E |
| Failed to ensure smoke barriers restrict smoke transfer due to cable and piping penetrations and missing drywall. | SS=E |
| Failed to install PTAC unit power cord end in accordance with NFPA standards, exposing wiring. | SS=D |
| Failed to conduct quarterly fire drills on all shifts; missing documentation for second shift fire drill in Q2 2024. | SS=D |
| Failed to inspect fire doors annually as required by NFPA 80 standards. | SS=F |
| Failed to ensure portable space heaters comply with NFPA standards; electric fireplace heat element not verified to be below 212°F. | SS=D |
| Failed to prepare and serve food under sanitary conditions including wet stacked dome lids, improper hand hygiene with glove use, and inaccurate food temperature monitoring. | SS=F |
| Failed to establish and maintain an infection prevention and control program; residents on Enhanced Barrier Precautions lacked proper signage and PPE outside rooms. | SS=E |
Report Facts
Deficiencies cited: 10
Facility capacity: 111
Census: 85
Fire drills missed: 1
Fire doors inspected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Director | Named in multiple findings including emergency lighting, exit signage, kitchen hood maintenance, smoke barrier penetrations, PTAC wiring, and fire door inspections. | |
| Maintenance Director | Named in findings related to emergency lighting, kitchen hood inspections, smoke barrier penetrations, and fire door inspections. | |
| Food and Beverage Director | Named in food safety deficiencies including improper food temperature monitoring and hand hygiene. | |
| Administrator | Named in multiple interviews verifying findings and overseeing corrective actions. | |
| Director of Nursing | Named in infection prevention and control deficiencies and corrective actions. | |
| Infection Preventionist Nurse | Named in infection control deficiencies and staff training. | |
| Minimum Data Set Nurse | Named in infection control deficiencies and order reviews. |
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