Ida Culver House Broadview

Missing annual reports, semi-annual reports, and smoke detector sensitivity reports for all buildings (A through E).

Building D: Annual 90-minute power test for emergency lighting had not been performed and documented.

Facility must maintain detailed documentation and maps of fire-rated construction locations, including annual inspection reports detailing testing dates, modifications, and repairs for Buildings A, B, C, D, and E.

Missing annual inspection reports, forward flow tests, trip tests, and quarterly reports across buildings A, B, C, D, and E. Deficiencies noted regarding full head replacement in Buildings A and C.

Building B: 2nd floor vertical fire rated door and kitchen vertical fire rated door lack documentation of testing.

Building A, 2nd floor: trash chute door latch gets stuck, preventing the chute from latching.

Building B, 3rd floor: dry storage room will not close and latch. Building D, 3rd floor: double doors by storage D324 will not latch.

The facility failed to implement the Negotiated Service Agreement for a resident requiring two-person assistance for transfers, resulting in the resident being assisted by only one caregiver during a fall.

Facility failed to ensure nurse delegation (ND) was in place for 3 of 5 residents receiving medicated skin treatments and medication administration by unlicensed staff.

Facility failed to include an alternate plan for bath aide services provided by a hospice agency for 1 resident and failed to update the NSA to reflect current health status/care needs for 2 other residents.

Facility failed to develop and implement systems that support safe medication service for 1 resident, resulting in the resident not receiving medication as prescribed.

Facility failed to implement its policy for proper and safe installation of a side bed rail for 1 resident, posing a risk of entrapment.

Facility failed to notify primary care physicians when medications were not given as ordered, resulting in residents receiving medications on non-ordered dates.

Facility failed to document monitoring of skin conditions for 2 residents, including lack of documentation for wound care and monitoring for infections.

Multiple emergency and exit lights throughout the facility were non-functional during testing.

Missing water fire extinguisher for pool chemical room; outdated inspections on building C fire extinguishers.

A building fire alarm panel batteries are older than five years.

Open electrical boxes in B building kitchen, broken electrical outlets in first floor conference room, and flammable storage in B building electrical room.

C building first floor, elevator lobby fire doors did not close.

B building kitchen appliance lineup does not match the suppression system.

Missing documentation for backflow internal inspection; expired gauges on sprinkler risers; damaged sprinkler head escutcheon; corroded/loaded/damaged sprinkler heads; recessed sprinkler head; paint on sprinkler head.

Unable to provide documentation for Fire Department Connection hydrostatic testing as required by NFPA 25.