Wesley Homes Lea Hill LLC

Facility unable to provide documentation for annual generator servicing, weekly inspection logs, or monthly 30 min load test.

The patio area had an uncovered electrical junction box.

Gas fired wheeled appliances in the kitchen were not tethered to wall.

Smoke detector near cooking appliances in the kitchen was heavily covered in grease.

Missing documentation for semi-annual kitchen suppression service; hood suppression heads missing grease caps and nozzles not pointed toward appliances.

Facility unable to provide documentation for annual fire extinguisher servicing and monthly inspection logs.

Facility unable to provide documentation that sensitivity test had been performed or nuisance log was kept.

Facility unable to provide documentation for monthly carbon monoxide alarm and detector testing.

The electrical closet had multiple items in front of electrical panels impeding required 36 inch clearance.

Facility unable to provide documentation for monthly smoke detector testing.

Facility unable to provide documentation for required sprinkler system testing (internal pipe, dry system, trip, forward flow, FDC hydro) and multiple sprinkler heads were loaded with dust/grease.

The fire door near the dining area did not latch from a fully open position.

The fire extinguisher near room 155 was obstructed.

Facility unable to provide documentation for their 90 min annual exit and emergency lighting power test.

Facility unable to provide documentation that annual fire door inspection had been performed.

Facility unable to provide documentation for their 30 second monthly exit and emergency lighting activation test.

Facility unable to provide documentation that fire drills were performed one per shift, per quarter over the last 12 months.

Facility unable to provide documentation that the 4 year fire/smoke damper inspection had been performed.

Electrical closet had penetrations in walls without fire resistance rated material installed.

Patio area had an uncovered electrical junction box.

Missing documentation for 5-year internal pipe test, 3-year dry system test, annual trip/forward flow tests, and 5-year FDC hydro test. Kitchen and laundry sprinkler heads were loaded with dust/grease.

Facility unable to provide documentation for annual fire door inspection.

Missing documentation for monthly carbon monoxide alarm and detector testing.

Fire door near the dining area did not latch from a fully open position.

Missing documentation for fire drills performed one per shift, per quarter over the last 12 months.

Electrical closet had penetrations in walls without fire resistance rated material installed.

Missing documentation for annual servicing, weekly inspection log, and monthly 30-minute load test.

Missing documentation for 30-second monthly emergency lighting activation test.

Smoke detector near kitchen cooking appliances was heavily covered in grease.

Missing documentation for semi-annual kitchen suppression service. Hood suppression sprinkler heads missing grease caps and nozzles not pointed toward fuel fire appliances.

Missing documentation for 90-minute annual power test.

Fire extinguisher near room 155 was obstructed.

Missing documentation for annual servicing and monthly inspection logs.

Facility unable to provide documentation for 4-year fire/smoke damper inspection.

Missing documentation for monthly smoke detector testing.

Gas fired wheeled appliances in the kitchen were not tethered to wall.

Missing documentation for sensitivity testing or nuisance log.

Electrical closet had multiple items in front of electrical panels impeding required 36" clearance.

Facility failed to ensure 2 of 4 care staff (Staff E and Staff F) met training requirements for CPR and first aid.

Facility failed to ensure Resident 2 received all medications as prescribed; no documentation explained missed doses.

Facility failed to conduct full assessments annually and failed to assess residents for safe use of medical devices (bed rails).

Staff failed to meet CPR and first-aid training requirements.

Mechanical ventilation not functioning in 2 of 2 common bathrooms.

Facility failed to ensure Staff B completed a national fingerprint background check.

Failure to document needed care services and safety plans for 3 of 6 residents (Residents 2, 3, and 5) in their Negotiated Service Agreements (NSA).

Facility failed to ensure Staff B was tested for TB within three days of employment.

Kitchen suppression nozzles over the deep fat fryer and part of the griddle are facing outward toward the back of the appliances.

Storage room door by room 147 is missing its door closure.

Facility unable to provide documentation for annual generator report and monthly load tests.

Facility unable to provide records of annual fire wall inspection and/or repairs.