Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Life Safety
Deficiencies: 6
Mar 18, 2025
Visit Reason
The inspection was conducted by the Office of the State Fire Marshal at The Belletini facility to investigate a complaint regarding the generator not transferring power properly and to assess compliance with fire safety codes.
Findings
The inspection found that the transfer switch on the generator would not manually transfer power from city power to generator power without manual switching. Several deficiencies were cited including the need for a policy and procedure on manual transfer power, a tracking chart, verification of emergency breaker status, and updates on replacement status. The facility was disapproved due to these deficiencies.
Complaint Details
Complaint #170723 regarding generator not transferring power properly. The complaint was investigated on 3/11/2025 by DSFM Jason Van Gorrkum. No injuries were sustained. The issue was identified as a building maintenance issue. Follow-up actions included scheduled service and staff education on manual power transfer.
Deficiencies (6)
| Description |
|---|
| Transfer switch would not manually transfer from city power to generator power without manual switching. |
| Facility needs to establish a policy and procedure on manual transfer power. |
| Policy and procedure must include how to contact and how to locate doors to access generator, maps or pictures of transfer switch, and step-by-step instructions for manual transfer. |
| Tracking chart needs to be developed and documentation available on re-inspection. |
| Verification needed on emergency breaker to identify possible issues with long stretch of power loose. |
| Facility must keep updates regarding replacement status. |
Report Facts
Complaint number: 170723
Scheduled service date: 2025.03
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorrkum | Deputy State Fire Marshal | Conducted the inspection and complaint investigation |
Inspection Report
Life Safety
Deficiencies: 15
Feb 18, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire protection inspection at the facility to assess compliance with fire safety codes and regulations.
Findings
Multiple deficiencies were identified including missing documentation for fire drills, use of extension cords inappropriately, heavy buildup behind filters, door maintenance issues, missing escutcheon in a resident room, missing smoke detector, exit sign deficiencies, and lack of required maintenance reports and inspections for emergency power and fire doors.
Deficiencies (15)
| Description |
|---|
| Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months; missing drills for 3rd shift - Quarter 1, 2, and 3. |
| Signature page showing employees on duty and participating in fire drills was not provided. |
| Extension cords found in use to commercial reach in refrigerator in bistro, multi power cord found in use sales office plugged in power strip, extension cord found strapped to sprinkler system on outside maintenance office. |
| Heavy buildup found behind filters; facility needs to increase to 3 cleaners in a 12 month colander year. |
| Facility needs to provide documentation of inspections and repairs for fire-resistant-rated construction; annual inspection of fire-resistance-rated construction will need to be performed and completed. |
| Double doors in hallway by room 510 were held open with a wedge. |
| Double doors in hallway by room 310 will not latch. |
| Missing escutcheon found in resident room 131 in bedroom. |
| Report did not indicate heat temperature for the fusible link and how many in use. |
| Deficiencies found on annual report dated 7/11/2024 were not provided. |
| Missing smoke detector in hallway outside room 510. |
| Exit sign is needed to show direction of path of egress located outside path gate. |
| Annual service report, log of weekly inspections, monthly 30-minute full load test, and diesel fuel testing for emergency and standby power systems were not provided. |
| Loose tank found in servers back room of Bistro. |
| Facility will need to provide documentation of locations of Fire Doors; inspections report will need to show testing date, modifications, and repairs; annual inspection of Fire Doors will need to be performed and completed. |
Report Facts
Missing fire drills: 3
Number of cleaners: 3
Annual report date: Jul 11, 2024
Next inspection scheduled: Mar 20, 2025
Inspection Report
Follow-Up
Capacity: 41
Deficiencies: 7
Jun 11, 2024
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies from earlier inspections completed on 04/16/2024 and 04/11/2024.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to tuberculosis testing and staff training were corrected.
Deficiencies (7)
| Description |
|---|
| Failure to ensure 4 of 6 staff were screened for tuberculosis within three days of employment, placing residents at risk of exposure to TB. |
| Failure to ensure 2 of 6 staff completed department approved continuing education training, placing residents at risk of unmet care needs. |
| Assisted living facility license and most recent full inspection report were not posted in a clearly visible area of the facility. |
| First aid kits were not readily available or clearly identified throughout the facility; disaster plan lacked required information on staff responsibilities, alternative accommodations, and emergency communication plan. |
| Laundry area did not provide separate areas for handling clean and soiled laundry, and lacked clearly marked entrances and exits. |
| Hot water temperatures in common bathrooms did not consistently reach required 105°F; facility adjusted temperature and implemented monitoring. |
| Resident apartments lacked lockable drawers or cabinets as required. |
Report Facts
Residents sampled: 7
Staff not screened for TB: 4
Staff not completing continuing education: 2
Resident apartments lacking lockable storage: 6
Total licensed capacity: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in tuberculosis testing deficiency; not screened for TB as required. |
| Staff B | Director of Health Services | Named in tuberculosis testing deficiency; completed only one-step TB skin test late. |
| Staff C | Caregiver | Named in tuberculosis testing deficiency; completed only one-step TB skin test late. |
| Staff D | Caregiver | Named in tuberculosis testing deficiency; incomplete two-step TB skin test. |
| Staff E | Medication Technician | Named in continuing education deficiency; incomplete CE documentation. |
| Staff F | Medication Technician | Named in continuing education deficiency; no documentation of required CE hours. |
| Laurie Anderson | Field Manager | Signed enforcement and follow-up inspection reports. |
| Steven Garrett | LTC Licensor | Conducted inspections and cited deficiencies. |
| Claudia Allis | Community Complaint Investigator | Conducted inspections and cited deficiencies. |
Inspection Report
Follow-Up
Deficiencies: 0
Dec 22, 2022
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, indicating that the facility met the Assisted Living Facility licensing requirements and corrected all prior deficiencies.
Report Facts
Compliance Determination Numbers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Forkgen | ALF Licensor | Department staff who did the on-site verification |
| Michelle Yip | ALF Licensor | Department staff who did the on-site verification |
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