Island House

The facility failed to update Care Plans (Negotiated Service Agreements) to include specific precautions and monitoring for 4 residents on anticoagulant medications.

The facility failed to complete a full annual assessment for 1 of 7 sample residents within 14 days of the resident's move-in date.

Facility could not provide documentation for 12 planned and unannounced fire drills across all three shifts for the previous 12 months.

Broken receptacle found in kitchen next to the 3 sinks.

No documentation for first or second semi-annual hood cleaning.

No established schedule for inspection of fire-rated construction.

Fire-resistance barrier penetrations observed in 3rd floor mechanical room, 2nd floor housekeeping, and 1st floor copier room.

Double door going into bistro will not close and latch.

Missing annual report, internal pipe testing, 3-year dry system test, FDC hydro test, and 4th quarter inspection. Painted sprinkler heads found in dining room and kitchen dry storage.

Missing semi-annual service documentation; nozzles were found pointed at wall.

Missing documentation for monthly single and multiple station alarm tests.

Fire/smoke damper inspection not performed and documented.

No annual fire door inspection documentation; adjustment needed for 2nd floor room 204.

The facility failed to provide a formal, legally compliant discharge notice to Resident 1 and their family; only an informal email was sent.

Failed to ensure staff completed required in-person CPR/first-aid training, continuing education, and specialized dementia/mental health training.

Failed to obtain certification from a veterinarian that pets were free of disease and/or up to date on vaccinations.

Failed to include necessary information in the Negotiated Service Agreement (NSA) for Resident 4, specifically failing to define observations/interventions for diabetes and catheter care.

Failed to ensure staff initiated TB screening within three days of hire for 2 of 6 sampled staff.

Failed to obtain a Medical Testing Site Waiver (MTSW/CLIA) and failed to implement a Respiratory Protection Program including medical clearance and mask fit-testing for staff.

Failed to ensure food was stored off the floor in the walk-in freezer to prevent contamination.

Failed to ensure staff received appropriate TB screening or provided proof of previous testing results.

Failed to safely store hazardous chemicals (cleaners, bleach) away from residents; housekeeping carts were left unattended and unlocked.

Failed to ensure staff received the second-step TB skin test within the required one to three-week timeframe.

1st floor outside of gate blocked.

Combustible material stored in 2nd floor electrical room (West) and 3rd floor mechanical room by 309 (East).

Facility failed to provide documentation for 12 planned/unannounced fire drills in the previous 12 months.

Documentation for first and second semi-annual hood cleaning was not provided.

No documentation provided for fire-rated construction inspection; schedule needs to be established.

Multiple fire doors throughout facility (3rd floor, 2nd floor, 1st floor, office, and garage) failed to latch.

Missing required testing/inspections documentation (internal pipe, dry system, forward flow, etc) and physical obstructions found at sprinkler heads.

Documentation for semi-annual servicing and annual replacement of fusible links/sprinkler heads not provided.

No documentation for monthly fire extinguisher inspections by facility maintenance.

Missing annual report, sensitivity testing, nuisance log, and NICET/ES/NTS certification.

Missing documentation for monthly testing; alarms needed in multiple locations including mechanical rooms and dining area.

Door failed to operate at time of inspection; no annual report provided.

Missing documentation for 30-second monthly activation test.

Missing documentation for annual 90-minute power test.

Missing annual service, weekly inspection logs, and full load tests for generator.

Carbon monoxide alarms and detectors require monthly testing/maintenance schedule and documentation. Several units observed missing in various rooms/floors.

Missing annual service, weekly inspection logs, and load test records. Generator panel requires assessment.

Fire/smoke damper 4-year inspection not performed or documented.

Annual report missing; door would not work at time of inspection.

Fire/smoke damper 4-year inspection not performed or documented.

Missing monthly inspection logs by facility maintenance.

Missing 30-second monthly activation test records.

Annual inspection of fire doors has not been established, performed, or documented.

Missing annual report, sensitivity testing, nuisance log, monthly alarm test logs, and NICET/ES/NTS certification.

Missing annual 90-minute power test records.

Failed to obtain department approval to increase bed capacity of 55 residents prior to admitting additional residents.

Failed to ensure that one staff completed in-person CPR training.

Failed to ensure two staff received tuberculosis (TB) screening in the form of blood or skin testing or provided proof of a previous positive test.

Failed to ensure one staff received a second-step tuberculosis (TB) screening test one to three weeks after the first step.