Inspection Report
Re-Inspection
Deficiencies: 9
May 9, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited violations related to fire safety and hood system compliance.
Findings
The facility was found to have multiple unresolved violations including grease accumulation in the hood system over kettles and oven, failure to provide fire door inspection reports, unsecured compressed gas cylinders, failure to provide annual fire resistance rated construction inspection, and failure to provide documentation for fire damper inspection and fire alarm system inspection. The facility remains disapproved.
Deficiencies (9)
| Description |
|---|
| Grease found in hood system over kettles and oven; facility moved appliance and added metal wall but needs to update hood suppression system. |
| Facility failed to provide fire door inspection report; multiple doors out of compliance throughout the building. |
| Compressed gas cylinders found unsecured in kitchen. |
| Facility failed to provide an annual fire resistance rated construction inspection in conjunction with inventory of fire rated construction. |
| Facility failed to provide documentation for fire damper inspection. |
| Facility failed to provide semi-annual fire alarm system inspection. |
| Portable fire extinguishers found to be expired. |
| Kitchen appliances shall be properly restrained; non-approved multi plug found in room 240. |
| Extension cord found in use in room 240. |
Report Facts
Next inspection scheduled date: Jun 8, 2025
Next inspection scheduled date: Apr 3, 2025
Next inspection scheduled date: Dec 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas D. Wolden | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on multiple pages. |
| Aaron Webster | Building Services Director | Signed as Owner or Authorized Representative on page 12. |
Inspection Report
Re-Inspection
Deficiencies: 12
Mar 4, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited violations.
Findings
Multiple fire safety violations were found uncorrected, including unsecured compressed gas cylinders, grease accumulation in the hood system, failure to provide annual fire resistance rated construction inspection, missing fire door inspection reports, lack of fire damper inspection documentation, expired portable fire extinguishers, and failure to provide semi-annual fire alarm system inspection.
Deficiencies (12)
| Description |
|---|
| Compressed gas cylinders found in kitchen unsecured |
| Grease found in hood system over kettles and oven; kitchen remodel not closed out by Construction Review Services; instructions lacking for new employees on fire extinguisher use |
| Facility failed to provide an annual fire resistance rated construction inspection in conjunction with inventory of fire rated construction |
| Facility failed to provide fire door inspection report; multiple doors found out of compliance |
| Facility failed to provide documentation for fire damper inspection |
| Facility found to change commercial cooking appliance and will need heat survey |
| Non approved multi plug found in room 240 |
| Extension cord found in use in room 240 |
| Kitchen appliances shall be properly restrained |
| Holes found throughout the building that appear to be in fire rated construction, including third floor laundry room |
| Portable fire extinguishers found to be expired |
| Facility failed to provide semi annual fire alarm system inspection |
Report Facts
Next inspection scheduled date: Apr 3, 2025
Previous inspection date: Nov 15, 2024
Next inspection scheduled date: Dec 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Wolden | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on inspection reports |
| Aaron Webster | Building Services Director | Signed as Owner or Authorized Representative on inspection report |
Inspection Report
Re-Inspection
Deficiencies: 12
Mar 4, 2025
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited violations related to fire safety and code compliance.
Findings
Multiple violations were found to be uncorrected, including grease in the hood system, unsecured compressed gas cylinders, failure to provide fire door inspection reports, failure to provide annual fire resistance rated construction inspection, expired portable fire extinguishers, and failure to provide semi-annual fire alarm system inspection.
Deficiencies (12)
| Description |
|---|
| Grease found in hood system over kettles and oven; facility moved appliance and added metal wall but needs to update hood suppression system. |
| Compressed gas cylinders found in kitchen unsecured. |
| Facility failed to provide fire door inspection report; multiple doors out of compliance. |
| Facility failed to provide annual fire resistance rated construction inspection with inventory of fire rated construction. |
| Portable fire extinguishers found to be expired. |
| Facility failed to provide semi-annual fire alarm system inspection. |
| Non-approved multi plug found in room 240. |
| Extension cord found in use in room 240. |
| Kitchen appliances shall be properly restrained. |
| Facility found to change commercial cooking appliance and will need new heat survey. |
| Holes found throughout building appearing in fire rated construction including third floor laundry room. |
| Facility failed to provide documentation for fire damper inspection. |
Report Facts
Provider Number: 1189
Next inspection scheduled date: Jun 8, 2025
Next inspection scheduled date: Apr 3, 2025
Next inspection scheduled date: Sep 27, 2025
Next inspection scheduled date: Dec 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas D. Wolden | Deputy State Fire Marshal | Signed inspection reports |
| Austin Beck | Maintenance Tech | Signed inspection report on page 2 |
| Aaron Webster | Building Services Director | Signed inspection report on page 14 |
Inspection Report
Follow-Up
Census: 111
Deficiencies: 4
Oct 21, 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 cited in the August 2024 full inspection were corrected.
Deficiencies (4)
| Description |
|---|
| Failure to document in residents' Negotiated Service Agreements (NSA) the plan to provide necessary health support services and specific care needs for 5 of 16 sampled residents. |
| Failure to ensure the NSA was agreed to and signed at least annually by the resident or responsible party for 4 of 16 sampled residents. |
| Failure to maintain a current resident characteristic roster accurately documenting care needs and services for 3 of 16 sampled residents. |
| Failure to complete tuberculosis two-step skin testing within required timeframe for 2 of 3 sampled staff. |
Report Facts
Sampled residents reviewed: 16
Sampled former residents reviewed: 0
Staff sampled for TB testing: 3
Staff with late TB testing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kyle Gehlen | ALF Licensor - LTC | Department staff who conducted inspections and verifications. |
| Jennifer Siharath | ALF Licensor | Department staff who conducted inspections and verifications. |
| Jacob Ubl | ALF NCI CI | Department staff who conducted inspections. |
| Staff A | Executive Director | Acknowledged deficiencies and corrective actions during exit interviews. |
| Staff B | Health Services Director | Provided information on resident care and acknowledged deficiencies. |
| Staff C | Caregiver | Sampled staff with late tuberculosis testing. |
| Staff D | Certified Medication Aide | Sampled staff with late tuberculosis testing. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Feb 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations that the facility failed to notify resident representatives of significant changes in residents' conditions and incidents, and concerns about calling emergency medical services instead of home hospice.
Findings
The facility failed to notify resident representatives of significant changes in condition and reportable incidents, resulting in a consultation. Staff and resident interviews, record reviews, and observations showed no concerns regarding quality of care or treatment, and documentation confirmed home hospice was notified. Facility staff called emergency medical services for support after resident falls without hospital transfer.
Complaint Details
Complaint investigation included allegations that the resident representative was not notified after resident change in condition and incidences, and that emergency medical services were called instead of home hospice. The investigation found the failure to notify resident representative but no concerns with quality of care or treatment.
Deficiencies (1)
| Description |
|---|
| Failure to notify resident representative of resident's significant change in condition and other reportable incidents. |
Report Facts
Total residents: 104
Resident sample size: 3
Compliance Determination Number: 19374
Complaint Number: 65926
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Ubl | ALF NCI CI Investigator | Department staff who conducted the inspection and provided consultation |
| Michael Burdick | Field Manager | Signed the letter regarding the complaint investigation |
Inspection Report
Life Safety
Deficiencies: 8
Nov 7, 2022
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Touchmark at Fairway Village facility on 11/07/2022.
Findings
The facility was found to have multiple fire safety violations including open electrical breaker panels, failure to maintain fire-resistance-rated construction, failure to provide required fire door repairs and testing, failure to maintain fire detection and alarm systems, and unsecured oxygen cylinders.
Deficiencies (8)
| Description |
|---|
| Open junction boxes and open-wiring splices with open breaker panel found |
| Failure to maintain inventory and proper fire-resistance-rated construction |
| Failure to repair fire doors and disabled self-closers on kitchen and assisted dining doors |
| Failure to provide 4 year fire damper testing |
| Failure to provide 5 year internal inspection and maintenance, annual forward flow testing, and 5 year FDC hydro testing |
| Fire alarm system found to have 3 troubles and one supervisory condition |
| Failure to provide monthly carbon monoxide detector testing |
| Oxygen cylinder found unsecured in Claremont RCM office |
Report Facts
Fire alarm troubles: 3
Fire alarm supervisory conditions: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Barnes | Block Senior NC | Owner or Authorized Representative who signed the inspection report |
| Nicholas Wolden | Deputy State Fire Marshal | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Nov 1, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding infection control failures, specifically the facility's failure to notify the department and local health department of a COVID-19 outbreak and failure to maintain fit testing of staff.
Findings
The facility failed to notify the department and local health department about a COVID-19 outbreak, failed to ensure staff wore fit-tested N95 respirators when caring for COVID-19 positive residents, and failed to conduct annual fit testing of staff, resulting in a failed provider practice and citation.
Complaint Details
The complaint alleged infection control failures related to notification of a COVID-19 outbreak and fit testing of staff. The investigation substantiated the complaint with failed provider practice identified and citation written.
Deficiencies (1)
| Description |
|---|
| Facility failed to notify the department and local health department of a COVID-19 outbreak and failed to maintain fit testing of staff. |
Report Facts
Total residents: 110
Resident sample size: 110
Staff members due for annual fit test as of June 2022: 73
Staff members due for annual fit test as of October 2022: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clinton Fridley | NCI, ALF Complaint Investigator | Investigator who conducted the complaint investigation |
| Jacob Ubl | ALF NCI CI | Department staff who did the on-site verification for follow-up inspection |
| Staff A | Registered Nurse (RN), Health Services Director (HSD) | Interviewed staff who stated facility was in COVID-19 outbreak and discussed notification failures |
| Staff C | Medication Aide | Interviewed staff who stated they had not been fit tested and were not trained to wear surgical mask under N95 |
| Staff D | Caregiver | Interviewed staff who stated they had been fit tested for a specific N95 respirator |
| Staff E | Caregiver | Interviewed staff observed wearing a black KN95 facemask and not fit tested for N95 |
| Staff F | Medication Aide | Interviewed staff who stated last fit testing was two years ago and no re-fit testing since |
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