Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Jun 5, 2025
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation based on allegations including cancelled doctor visits, long call light wait times, postponed activity trips due to money, and laundry not being done on certain floors due to lack of soap.
Findings
The investigation found that the facility failed to provide a Disclosure of Services form to residents, and failed to include activity preferences in resident assessments for 11 residents in the Memory Care Units. No issues were found with cancelled doctor visits, call light wait times, or laundry services. The facility was cited for these deficiencies.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to provide a Disclosure of Services form and failed to include activity preferences in resident assessments. Other allegations such as cancelled doctor visits, long call light wait times, and laundry issues were not substantiated.
Deficiencies (2)
| Description |
|---|
| Failed to develop or provide a Disclosure of Services form describing the scope of care and services, resulting in 80 residents not knowing the level of care and services available. |
| Failed to ensure resident assessments included preferences for hobbies and activities for 11 residents in Memory Care Units, risking lack of tailored activity programs. |
Report Facts
Total residents: 80
Resident sample size: 14
Residents with missing activity preferences: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Conducted the complaint investigation and off-site verification |
| Jamie Singer | Field Manager | Signed the follow-up inspection report confirming no deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 17
May 6, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously identified fire safety violations.
Findings
The inspection found that several deficiencies related to fire door inspection, fire/smoke damper inspection, and emergency evacuation drills had not been corrected or documented. Multiple required inspection and maintenance reports were missing or incomplete.
Deficiencies (17)
| Description |
|---|
| Facility will need to identify and establish a schedule for inspection of Fire Doors. Annual inspection of fire doors will need to be performed and completed. |
| Fire/smoke damper inspection will need to be performed and documented. |
| Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months. Specific drills missing include 1st, 2nd, and 3rd shift quarters 1, 2, 3, and 4. |
| Missing cover on receptacle found in Memory Care #1 nurses desk. |
| Power strip plugged into another power strip found in wellness office. |
| First and second semi-annual hood cleaning documentation missing. |
| Stairwell Door by room 226 will not latch; Double doors by elevator second floor will not latch. |
| Missing annual report, 5-year internal pipe testing, 3-year dry system full flow trip test, annual trip test, annual fire pump, 5-year FDC hydro testing, and quarterly inspections documentation. |
| Missing escutcheon found in basement housekeeping room. |
| First and second semi-annual servicing of automatic fire-extinguishing systems documentation missing. |
| Annual report, sensitivity testing, and monthly single and multiple station alarms test documentation missing. |
| Sensitivity testing documentation missing. |
| Carbon Monoxide Alarms and Detectors need to be tested, maintained, and documented on a monthly schedule. |
| Monthly 30-second activation testing of emergency lighting equipment had not been performed and documented. |
| Annual 90 minute power test of battery-powered emergency lighting equipment had not been performed and documented. |
| Annual service report, log of weekly inspections, monthly 30-minute full load test, and diesel fuel testing documentation missing. |
| Facility will need to identify and establish a schedule for inspection of Fire Doors. Annual inspection of fire doors will need to be performed and completed. |
Report Facts
Missing fire drills: 12
Missing fire drills: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Signed the inspection report |
| Adrian Perez Alonso | Maintenance Assistant | Signed as Owner or Authorized Representative |
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