The Inn at Arbor Village

The December 30, 2024 inspection identified 12 fire and life safety violations including a loaded sprinkler head near resident room 303, malfunctioning fire alarm in trouble status, fire doors failing to close/latch properly, and missing documentation for critical safety system inspections (sprinkler, kitchen suppression, fire wall, hood cleaning). The facility responded promptly and effectively, correcting all violations within approximately 2 months as confirmed by the March 4, 2025 reinspection showing full compliance. While the initial violations presented serious life-safety concerns in a residential care setting, the facility's systematic remediation demonstrated good response quality.

The facility failed to document a resident's pacemaker and monitoring requirements in their Negotiated Service Agreement, despite the device being noted in the assessment. Staff were unaware of the pacemaker or how to monitor for complications, placing the resident at risk for unmet cardiac care needs. The facility acknowledged the documentation gap, submitted a correction plan within 10 days, and completed all corrective actions by the follow-up inspection on 09/23/2024, with no deficiencies found upon re-inspection.

This residential care facility had severe and systemic fire and life safety violations across multiple critical areas including malfunctioning fire doors, missing documentation for sprinkler systems/fire dampers/emergency generator maintenance, improper fire alarm circuit identification, inadequate fire drills, and multiple equipment maintenance failures. The facility corrected some violations immediately during the initial inspection and addressed most issues by the re-inspection, but two critical deficiencies remained unresolved (kitchen fire door still not latching, missing damper/sprinkler documentation), resulting in continued disapproval status. The pattern of missing safety system documentation and testing records, combined with physical failures of life safety equipment, indicates systemic compliance failures that created substantial fire safety risks for vulnerable residents.

This residential care facility had multiple life-safety violations including failed fire suppression backflow devices, non-functioning fire doors, missing sprinkler equipment, inadequate fire drill documentation, and compromised smoke barriers. The facility corrected all violations within approximately two months through multiple re-inspections, demonstrating commitment to compliance. The systemic nature of violations across fire protection systems (suppression, detection, egress) and missing safety documentation indicated serious gaps in maintenance and emergency preparedness that could endanger residents during a fire emergency. The facility's prompt corrective action and successful completion of all repairs by March 2023 showed adequate responsiveness to regulatory findings.