Spiritwood at Pine Lake

Facility failed to submit background authorization for 1 contracted staff member within one business day of their start date.

Facility failed to ensure 1 staff member completed an initial TB skin test within three days of hire.

Facility failed to ensure 2 staff members with positive TB tests completed a chest x-ray within seven days.

Facility failed to ensure 1 of 3 pets was current on vaccinations and certified free of diseases transmittable to humans.

The facility did not post or make menus available in the memory care unit and failed to make the dietary manual available to kitchen staff.

Facility failed to assess 2 residents for the safe use of medical devices (bed rails).

The facility failed to keep the garbage refuse station clean and well-maintained. Observations showed trash, latex gloves, and debris scattered outside dumpsters and the facility kitchen, creating potential health risks.

The facility failed to assess Resident 6 and Resident 11 for the use of bed rails, which were installed by family members without the facility's knowledge.

Facility failed to update Negotiated Service Agreements for 2 residents regarding the use and maintenance of medical devices (Roho cushions).

Failure to ensure staff followed hand sanitation guidelines; uncorrected deficiency from 04/14/2025.

Failed to ensure four pets were current with examinations and certifications; uncorrected deficiency from 04/14/2025.

Failed to update two residents' Negotiated Service Agreements (NSA); uncorrected deficiency from 04/14/2025.

One staff failed to follow hand sanitation guidelines in the main commercial kitchen.

Periodic inspection and testing required.

Monthly carbon monoxide alarm/detector testing and maintenance documentation missing.

Multiple doors failed to latch automatically (e.g., by room 337, med room, laundry, activity room, and by elevator).

Med cart obstructing the path of egress in the elevator lobby.

Fire alarm and fire detection system maintenance records.

Missing annual inspection schedule and records for fire doors.

Missing annual reports, 5-year pipe/FDC tests, 3-year dry system tests, trip tests, flow tests, and quarterly inspections; loaded sprinkler heads observed.

Hoods, grease-removal devices, fans, ducts, and other appurtenances require cleaning.

Missing annual 90-minute battery power test documentation.

Opening protectives in fire-resistance-rated assemblies need inspection and maintenance.

Automatic fire-extinguishing systems service documentation.

Facility lacked documentation for fire-rated construction inspection schedule; penetrations found in 301D electrical room and 2nd-floor housekeeping room.

Facility failed to maintain five medications in original containers with pharmacy labels.

Facility did not display or have clearly marked signage for first aid kits.

Daisy-chained power strips in room 321, extension cord in courtyard, and extension cord found in memory care on TV wall.

Missing annual inspection record of fire-resistance-rated construction.

Missing annual report, sensitivity testing, and nuisance log.

Supplies stored under sprinkler heads in 3rd floor storage room and 2nd floor storage room.

Missing documentation for 4-year fire/smoke damper inspection.

Missing annual fire door inspection documentation.

Missing documentation for semi-annual servicing, annual replacement of fusible links/heads, and NAFED certification.

Unprotected penetrations noted near mail boxes, stairwell by room 103, above dish room exit, and above kitchen fire doors.

Missing records for 5-year internal pipe test, 3-year dry system test, annual forward flow test, 5-year backflow internal test, 5-year FDC hydro test, and quarterly inspections.

Corridor door and electrical door by room 341 will not latch.

Lack of exit signage showing direction of egress from courtyard to parking lot.

Carbon monoxide detector not working by resident mail room.

Electrical room and boiler room being used for storage.

Missing documentation for second semi-annual hood cleaning.