Inspection Report
Life Safety
Deficiencies: 6
Sep 11, 2025
Visit Reason
The Office of the State Fire Marshal conducted an inspection at South Pointe Assisted Living to assess compliance with fire safety codes.
Findings
The inspection identified multiple fire safety violations including an electrical outlet without a faceplate, use of unlisted multi-plug adapters, power strips plugged into other power strips, extension cords used as permanent wiring, disabled automatic closure on a fire rated door, and lack of visible fire department connection signage.
Deficiencies (6)
| Description |
|---|
| Electrical outlet without a faceplate in the DON office exposing inner electrical fixture. |
| Multi-plug adapter unable to be verified as UL 498A listed in room 111. |
| Power strip plugged into another power strip in room 111. |
| Extension cord utilized as permanent wiring in room 101. |
| Automatic closure for fire rated door from dining room to kitchen disabled, preventing door from closing upon fire alarm activation. |
| Fire department connection not visible from the street; no signage installed. |
Report Facts
Provider Number: 2610
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection |
| Rachelle Lloyd | Owner or Authorized Representative who signed the report |
Inspection Report
Routine
Deficiencies: 0
Apr 7, 2025
Visit Reason
The Department completed a full inspection of the Assisted Living Facility on 04/07/2025 to determine compliance.
Findings
The inspection found no deficiencies in the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Condyles | ALF Licensor | Department staff who did the inspection |
| Steven Kindle | Department staff who did the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 18, 2024
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A complaint was investigated regarding a fire in a cigarette receptacle at the facility.
Findings
The facility was unable to identify the cause of smoldering cigarettes in and around the cigarette receptacle. Staff extinguished the smoldering cigarettes with water, and the facility replaced the cigarette containers as a plan of correction. No violations were cited.
Complaint Details
Complaint ref #140352 regarding fire in cigarette receptacle. The cause was cigarettes, no sprinklers activated, no evacuation, no injuries, and no fire department response. Complaint was not substantiated with violations.
Report Facts
Complaint reference number: 140352
Time of inspection: 1100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara McMullen | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the inspection |
Inspection Report
Life Safety
Deficiencies: 15
Aug 19, 2024
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at South Pointe Assisted Living to assess compliance with fire protection and safety codes.
Findings
The facility was found to have multiple violations including improper listing of power taps, failure to provide documentation for semi-annual hood cleaning, unrepaired fire barriers, deficiencies in sprinkler and kitchen suppression systems, missing locking device on fire alarm system breaker, lack of documentation for smoke detector sensitivity testing, carbon monoxide detector testing, emergency lighting activation and power tests, unsecured oxygen cylinders, and incomplete fire drill records.
Deficiencies (15)
| Description |
|---|
| Multi-plug adapters without over current protection in rooms 215 and 217 |
| Facility unable to provide documentation for semi-annual hood cleaning |
| Unrepaired fire barriers with holes in ceilings of rooms 119 and beauty shop |
| Facility unable to provide documentation for annual fire resistance rated construction material inspection |
| Fire rated door from resident laundry room to corridor would not close and latch fully |
| Annual sprinkler inspection had deficiencies not corrected; no documentation for 5 year internal piping inspection |
| Semi-annual kitchen suppression system inspection had deficiencies not corrected |
| Power breaker #28 for fire alarm system missing locking device |
| Facility unable to provide documentation for required smoke detector sensitivity testing |
| Facility unable to provide documentation for monthly carbon monoxide detector testing |
| Trash and supplies blocking emergency exit at rear exit pathway near sprinkler room |
| Facility unable to provide documentation for monthly 30 second activation test for emergency lights |
| Facility unable to provide documentation for annual 90 minute power test for emergency lights |
| Oxygen cylinders in rooms #221 and #218 not secured to prevent falling |
| Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in previous 12 months; multiple shifts missing drills |
Report Facts
Number of missing fire drills: 12
Dates of inspection: Aug 19, 2024
Next inspection scheduled on or after: Sep 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Rachelle Lloyd | Owner's Representative | Signed the inspection report |
Inspection Report
Follow-Up
Census: 34
Deficiencies: 2
Aug 15, 2024
Visit Reason
The Department completed a follow-up inspection of South Pointe Assisted Living Facility to verify correction of previously identified deficiencies.
Findings
The follow-up inspection on 08/15/2024 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior complaint investigation identified failures in specialized training for mental illness and dementia, resulting in citations.
Complaint Details
Complaint investigation conducted from 03/13/2024 through 06/18/2024 regarding multiple allegations including unattended medical appointment, lack of nurse coverage, unreported wound, inadequate care, falsified training certificates, and forged signature. The investigation found failed provider practices related to specialized training for mental illness and dementia.
Deficiencies (2)
| Description |
|---|
| Failure to ensure 2 of 3 staff completed specialized mental health training, resulting in staff not trained to provide care to residents with mental health diagnoses. |
| Failure to ensure 2 of 3 staff completed specialized dementia training, resulting in staff not trained to provide care to residents with dementia. |
Report Facts
Total residents: 34
Resident sample size: 3
Staff members not completing mental health training: 2
Staff members not completing dementia training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Condyles | ALF Licensor | Conducted the complaint investigation and follow-up inspection |
| Kimberley Ripley | Field Manager | Signed follow-up inspection letter |
| Staff D | Caregiver/Medication Technician | Failed to complete specialized mental health and dementia training |
| Staff E | Caregiver | Failed to complete specialized mental health and dementia training |
| Staff A | Executive Director | Provided statements regarding training and facility operations |
| Staff B | Vice President | Confirmed Staff D and Staff E did not complete required specialty training |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 13, 2024
Visit Reason
The Department completed a follow-up inspection of South Pointe Assisted Living Facility on 06/13/2024 to verify correction of previously cited deficiencies related to medication availability.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to nonavailability of medications were corrected.
Report Facts
Compliance Determination Completion Date: Completion dates 06/13/2024 and 03/14/2024 referenced
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Condyles | ALF Licensor | Department staff who did the on-site verification during follow-up inspection |
| Kimberley Ripley | Field Manager | Signed the follow-up inspection letter |
Inspection Report
Enforcement
Deficiencies: 1
Mar 14, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to South Pointe Assisted Living to address previously cited deficiencies and enforce compliance, resulting in the imposition of a civil fine.
Findings
The facility failed to ensure prescribed medications were obtained in a timely manner for two residents, resulting in one resident missing twenty-two doses and another missing five doses, placing both at risk for medical complications. This deficiency was previously cited and remains uncorrected.
Deficiencies (1)
| Description |
|---|
| Failure to ensure prescribed medications were obtained in a timely manner for two residents, resulting in missed doses and risk of medical complications. |
Report Facts
Civil fine amount: 600
Missed medication doses: 22
Missed medication doses: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
| Kim Ripley | Field Manager | Contact person for plan of correction and appeals |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Jan 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations including medication administration errors, failure to notify Power of Attorney after a resident injury, lack of a full-time nurse, and failure to provide required N-95 masks during a COVID outbreak.
Findings
The investigation found two deficiencies: the facility administered a discontinued medication to a resident and failed to notify the resident's Power of Attorney after a fall causing injury. The facility lacked a full-time nurse temporarily but had clinical support, and the COVID outbreak was managed appropriately with no failed practice.
Complaint Details
The complaint investigation was substantiated with failed provider practice identified and citations written for medication administration and failure to report significant change in resident condition. The investigation involved interviews, observations, and record reviews from 01/09/2024 through 03/20/2024.
Deficiencies (2)
| Description |
|---|
| Resident was given a medication that had been discontinued by the physician. |
| Failure to notify the Power of Attorney of a resident's fall and injury. |
Report Facts
Total residents: 34
Resident sample size: 4
Closed records sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Condyles | ALF Licensor | Investigator who conducted the complaint investigation and on-site verification |
| Kimberley Ripley | Field Manager | Signed correspondence related to inspection and compliance |
| Staff B | Director of Nursing | Interviewed regarding nursing coverage and hospital discharge order review |
| Staff A | Executive Director | Involved in assessment and notification processes related to resident fall |
| Staff D | Medication Technician | Administered medication and involved in fall incident reporting |
Inspection Report
Life Safety
Deficiencies: 11
Aug 31, 2023
Visit Reason
The Office of the State Fire Marshal conducted an inspection at South Pointe Assisted Living to assess compliance with fire safety and protection regulations.
Findings
The facility was found to have multiple violations including unapproved electrical outlet conditions, lack of documentation for semi-annual hood cleaning, annual fire resistance construction inspection, sprinkler system inspection, kitchen suppression system servicing, fire alarm system testing, monthly carbon monoxide detector testing, emergency lighting activation tests, and fire drills. Additionally, physical obstructions to fire extinguishers and malfunctioning door-closing coordinators were noted.
Deficiencies (11)
| Description |
|---|
| Electrical outlet without a faceplate in the boiler room exposing inner electrical fixture |
| Facility unable to provide documentation for semi-annual hood cleaning |
| Facility unable to provide documentation that annual fire resistance rated construction material inspection has been completed |
| Doors to activity room had an inoperative door-closing coordinator preventing doors from closing and latching |
| Facility unable to provide documentation for annual sprinkler system inspection and 5 year internal piping inspection |
| Facility unable to provide documentation for semi-annual kitchen suppression system servicing; kitchen suppression system yellow tagged by service provider |
| Portable fire extinguisher near Executive Director's office was obstructed by a chair |
| Facility unable to provide documentation for annual fire alarm system testing; smoke detector heads installed within 36 inches of air supply diffuser or return air opening preventing proper operation |
| Facility unable to provide documentation for monthly carbon monoxide detector testing for July |
| Facility unable to provide documentation for monthly 30 second activation test for emergency lights for July |
| Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in the previous 12 months; multiple shifts and quarters missing |
Report Facts
Next inspection scheduled on or after: Sep 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandon G. Brown | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the inspection |
| Jennifer Barnes | Business Office Manager | Named as Owner or Authorized Representative on disapproval report |
| Paul Barrans | Manut Dir. | Named as Owner or Owner's Representative on approval report |
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