Spiritwood at Pine Lake

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

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

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.

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

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

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

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.

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

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

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

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

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

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

Automatic fire-extinguishing systems service documentation.

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

Missing annual 90-minute battery power test documentation.

Missing annual inspection schedule and records for fire doors.

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

Fire alarm and fire detection system maintenance records.

Periodic inspection and testing required.

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

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

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

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

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

Electrical room and boiler room being used for storage.

Missing documentation for second semi-annual hood cleaning.

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

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

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

Carbon monoxide detector not working by resident mail room.

Missing annual fire door inspection documentation.

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

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

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.

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

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

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

Missing annual report, sensitivity testing, and nuisance log.