Assisted Living on Jensen

Facility converted a resident room (Room 228) to an office/storage without notifying or obtaining approval from construction review services.

Facility failed to ensure 1 of 1 kitchen maintained a dietitian approved diet manual available for use by staff.

Facility failed to ensure 1 of 6 staff (Staff B) completed the required 70-hour basic training while providing care to residents.

Facility failed to ensure safe food handling practices; kitchen staff used an eyewash station to wash hands instead of a handwashing sink; test strips for sanitizing solution had expired in 2023.

The fire alarm panel network remains in trouble status and may not be communicating properly.

Facility failed to conduct fire watch in 15-minute intervals as required by policy, instead conducting them in 30-minute intervals.

Discarded cigarette butts found on ground and in brush in smoking area (04/24/2025). Corrected by 07/07/2025.

Multiple fire doors failed to latch/close. Re-inspection 07/07/2025 noted cross corridor FD 17 still failed.

Unable to provide annual inspection records for fire alarm system (04/24/2025). Corrected by 07/07/2025.

Facility unable to provide documentation for current hood cleaning (04/24/2025). Corrected by 07/07/2025.

Missing sprinkler reports and 5-year internal pipe inspection (04/24/2025). 5-year inspection rescheduled for 07/07/2025.

Missing smoke detector sensitivity report and no nuisance log maintained (04/24/2025). Corrected by 07/07/2025.

Unable to provide record of annual fire wall inspection/repairs (04/24/2025). Corrected by 07/07/2025.

Kitchen fire suppression tags marked yellow/deficient (04/24/2025). Corrected by 07/07/2025.

Missed fire extinguisher monthly sign offs (04/24/2025). Corrected by 07/07/2025.

Facility unable to provide inventory record of annual inspection and/or repairs for all fire-resistant-rated doors.

Loaded/painted sprinkler heads and missing escutcheon rings found in various locations; facility failed to provide maintenance documentation.

Extinguisher in Activities office not maintained in accordance with NFPA 10.

Facility unable to provide documentation for last smoke detector sensitivity test report.

Multiple doors (cross-corridors, resident rooms, kitchen) did not close/latch properly when tested.

Facility unable to provide documentation for annual reports, trip tests, quarterly inspections, and forward flow tests.

Extinguisher in outside storage room mounted above 5 foot requirement.

Exit sign by room 226 did not work when tested.

Nurses room by the reception desk had a power strip dangling by the cord.

Fire damper report showed failed dampers; facility unable to provide documentation of correction.

Facility unable to provide documentation for current kitchen suppression servicing.

Fire alarm report showed deficiency due to backflow rope tampers not reporting to panel; missing circuit breaker lock.