Wellsprings of Gilbert

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Based on observation, it was determined that the facility failed to ensure that all parts of the facility were provided with sprinkler system coverage. Failing to provide sprinkler coverage in all areas of the facility by blocking the sprinkler heads could result in the sprinkler not controlling the fire, which could cause harm to the patients.

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, which will cause harm to the patients and/or staff.

Based on observation, the is missing exit signage above the nurses station in “A” wings that is the designated exit path per wall signage for evacuation. No exit signage could cause harm to the patients and/or staff in the event of a fire or emergency.

Based on observations during the tour conducted on December 2, 2025, it was determined that the facility failed to ensure that a restraint chain (tether) was properly installed on the kitchen appliances to protect the gas connection. Failure to protect connections on appliances that are on casters or wheels can result in a rupture of gas or electric connections, resulting in a risk of fire events.Â

Based on observation and interviews the facility failed to provide automatic sprinkler protection for the attached pergola on the south side of the building. The pergola is over four feet in width. Failing to provide automatic sprinklers to all areas of the facility could cause harm to residents and/or staff in time of a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater." (1.) NFPA 13, Standard for the Installation of Sprinkler Systems" NFPA 13, Section 8.15.7 Exterior roofs, Canopies, Porte-Cochers, Balconies, Decks or Similar Projections. Section 8.15.7.1 Unless the requirements of 8.15.7.2,8.15.7.3 , or 8.15.7.4 are met sprinklers shall be installed under exterior roofs, canopies, Porte-cocheres, balconies decks, or similar projections exceeding 4 ft in width. Findings include: Observations made while on tour on October 8, 2024, revealed a wooden pergola that is tied into the building on the south side of the building was not sprinklered. The pergola extends ten feet off the building. Management staff acknowledged during the facility tour and exit conference on October 8, 2024.

Based on observation the facility failed to properly seal drywall patches above the ceiling tiles of the therapy room fire doors and the wall to the right of the door. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire-resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires, and similar items to accommodate electrical, plumbing, and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke. Findings include: Observations made while on tour on October 08, 2024, observations above the ceiling tiles revealed drywall repairs measuring approximately 4 inches by 4 inches above the fire doors of the therapy room, and the wall to the right of the door were not properly sealed. The management team again acknowledged the above-listed findings during the exit conference on October 8, 2024.