Nikkei Manor

The October 2025 inspection identified five fire safety violations at this residential care facility, including damaged electrical equipment, improper gas appliance connections, missing fire sprinkler components, absent kitchen fire suppression signage, and inadequate fire extinguisher warnings. These violations presented moderate safety concerns related to fire protection systems but did not constitute immediate life-safety threats. The facility responded appropriately by correcting all violations prior to the February 2026 re-inspection, demonstrating good compliance and timely remediation of identified deficiencies.

This facility demonstrated a persistent pattern of serious medication administration violations across multiple inspections (June 2025, August 2025, and September 2025), where non-licensed staff administered medications without required nurse delegation to multiple residents, violating state nursing practice acts and the facility's own policies. Additional violations included failure to conduct required cognitive assessments for residents with dementia, incomplete negotiated service agreements lacking backup care plans, staff training deficiencies, and unsafe bed rail installation creating entrapment hazards. The facility responded appropriately by correcting all cited deficiencies by November 2025 as verified through follow-up inspections, though the recurring nature of medication delegation violations (previously cited in December 2023) indicates systemic issues requiring sustained corrective action and improved monitoring systems to prevent future recurrence.

The facility committed a severe and repeated violation by allowing non-licensed staff to administer medications to two residents without proper nurse delegation, creating significant risk for compromised health conditions. This represents a pattern of systemic failure, as the same violation was cited three times within nine months (June 2025, August 2025, and September 2025), with an earlier occurrence in December 2023. The facility's response has been inadequate, as evidenced by the recurring nature of the violation and the state's escalation to civil fines, indicating failure to implement or sustain effective corrective actions despite multiple opportunities. The $1,000 fine and formal enforcement action reflect the state's determination that the facility has not meaningfully addressed fundamental medication administration safety requirements.

The facility committed a severe medication administration violation when non-licensed staff administered medications without required nurse delegation training to a resident, creating significant risk of harm. This represents a recurring systemic failure, previously cited in June 2025 and December 2023, demonstrating persistent non-compliance with nursing service requirements. The facility's response has been inadequate, as evidenced by the recurrence of the same violation despite prior citations and corrective action requirements. The state imposed a $500 civil fine due to the uncorrected nature of this serious medication safety deficiency.

The facility failed to properly develop Negotiated Service Agreements (NSAs) for three residents, including inadequately defining private caregiver roles for two residents and lacking an alternate plan for hospice bath aide services for another resident. This is a recurring deficiency previously cited in December 2023 and March 2024, resulting in a $500 civil fine. The facility was given 10 days to submit a plan of correction, and the report indicates this is a pattern of non-compliance rather than an isolated incident. The recurring nature and lack of sustained correction demonstrates inadequate facility response to previously identified issues.

The December 2024 inspection identified moderate fire safety documentation and maintenance violations including missing annual inspection records for fire-rated construction, fire doors, smoke detectors, and backflow testing, plus physical issues like a broken ceiling tile and debris-loaded sprinkler head. The facility demonstrated a good response by correcting all violations within approximately 7 weeks, as confirmed by the February 2025 follow-up inspection showing full compliance. These were primarily administrative and maintenance deficiencies rather than immediate life-safety hazards, and the timely remediation demonstrates appropriate facility responsiveness to regulatory requirements.

The facility had two violations: incomplete Negotiated Service Agreements for four residents (recurring deficiency from 2022 and 2023) and failure to conduct required respirator fit-testing during a COVID-19 outbreak, placing 39 residents and staff at potential exposure risk for four days. Both deficiencies were previously cited and remained uncorrected, demonstrating a pattern of non-compliance. The facility was issued $900 in civil fines, but the report does not document specific corrective actions taken, indicating an incomplete response to systemic compliance issues.

The October 2023 inspection identified 10 fire safety violations at Nikkei Manor, including missing carbon monoxide alarms in the boiler room, non-functioning emergency lighting, improperly operating fire doors, missing documentation for fire-rated construction inspections, and kitchen hood suppression system servicing issues. The facility responded appropriately by correcting all violations within 6 weeks, as confirmed by the November 2023 follow-up inspection showing full compliance. While the violations represented a pattern of maintenance and documentation gaps affecting life safety systems, none posed immediate danger to residents, and the facility's timely comprehensive remediation demonstrates adequate corrective action.

The January 2023 inspection identified multiple fire and life safety violations including unapproved space heaters, malfunctioning fire doors and rolling doors, overdue damper inspections, missing sprinkler documentation, a defective sprinkler head, and an unsecured oxygen cylinder. While these violations represent a pattern of maintenance and safety system compliance issues with potential for resident harm, none created immediate life-threatening conditions. The facility responded appropriately by correcting all violations by the March 2023 follow-up inspection, demonstrating timely remediation and commitment to compliance.