Holden at Southcenter

The inspection identified 22 violations primarily related to fire safety systems maintenance and documentation, including missing sprinkler system testing records, CO detector testing documentation, incomplete fire drill records, and various correctable physical deficiencies like obstructed fire extinguishers and improperly secured equipment. The facility demonstrated a good response by correcting 19 of 22 violations by the follow-up inspection, with only three documentation-related items remaining. No immediate life-safety hazards were present, and the violations represented systemic maintenance and documentation gaps rather than fundamental safety failures.

The facility had a single deficiency related to improper hot and cold holding temperatures for potentially hazardous foods, which was corrected by 10/06/2025. All other kitchen areas including food preparation, dish washing, storage facilities, and food labeling were found to be clean, well-maintained, and in compliance with regulations. The facility demonstrated good operational practices overall with prompt correction of the temperature control issue within the investigation timeframe.

Fire Marshal inspection identified multiple code violations primarily related to documentation gaps (missing ITM records for sprinkler systems, CO detector testing, fire-resistance-rated construction inspections, and incomplete fire drill records) and immediate physical hazards (burning materials in trash, combustibles in exit stairways, open electrical boxes, blocked fire doors). Most violations were corrected on-site during the inspection, demonstrating responsive facility management. The facility cooperated with corrections but showed systemic documentation deficiencies requiring follow-up inspection scheduled for 11/22/2025.

The facility demonstrated a pattern of serious fire and life safety violations across multiple inspections, including malfunctioning fire alarm systems in trouble status, missing documentation for critical safety system inspections (sprinklers, kitchen suppression, fire doors), improperly maintained fire protection equipment, and unsafe electrical practices in resident areas. The facility showed moderate response efforts by scheduling required inspections and correcting some violations between the May and August inspections, but failed to fully resolve systemic documentation gaps and equipment deficiencies, requiring multiple re-inspections before achieving approval. The persistent fire alarm deficiencies and missing safety system documentation created ongoing life safety risks until final correction.