Face-to-face observations in areas were people were known to be at risk of suicide, assault, mental illness, or behavioral issues were confined were exceeded by 1 to 48 minutes on a routine basis.
Observation checks of people restrained with the restraint chair were conducted from 1 to 25 minutes over the required 15-minute time frame on multiple occasions.
Staffing is not sufficient to perform required functions within the facility. Areas found to be affected include food preparation, restraint checks, and observation checks.
Food is routine prepared in the kitchen by people without staff supervision.
Multiple staff members did not receive required quarterly training in 2021 and 2022.
The inspection of the ANSUL (life safety) system located in the kitchen is out of date by three months (last inspected in December 2021).
The transfer switch for the facility generator was inoperable. Records show the switch has been inoperable since April 2021 and repairs have not been conducted.
Full load tests of the facility generator have not been conducted since April 2021.
A log of The Veteran Reentry Search Service with identifying number and whether a referral card was issued to the identified veteran prior to release has not been maintained for five months.