Keystone

Facility failed to ensure resident confidentiality by storing two 'Confidential Identifier' (ID) lists inside a binder accessible to reviewers, posing privacy risks to 63 residents.

Facility failed to obtain client signatures on their policy for accepting Medicaid as a payment source.

Sprinkler heads loaded with debris in kitchen area.

Failed to maintain fire alarm system; report indicates some smoke alarms do not report to panel.

Obstructed exit path in basement hallway due to various items, including two BBQ grills.

Facility failed to pass initial fire inspection and two subsequent follow-ups due to debris on kitchen sprinklers, smoke alarms not reporting to panel, and obstructed basement exit paths.

Facility failed to maintain exit path in basement hallway; obstructed by various items including two BBQ grills.

Facility failed to maintain fire alarm system; report from 3/1/24 indicates smoke alarms did not report to the panel.

Missing documentation for five-year internal pipe inspection and quarterly reports. Sprinkler heads blocked by debris in hallway and kitchen. Fire sprinkler riser blocked by stored items.

Facility failed to provide documentation showing annual inspection of all fire-resistance-rated construction.

The facility failed to provide a resident (Resident 1) with a written discharge letter containing all required information after an incident where the resident was arrested and informed they were not allowed to return.

The facility failed to ensure 1 of 1 staff members (Staff C) completed the required one-step tuberculin skin test (TST) within three days of hire date.

Completed deficiencies report for annual fire alarm system inspection was not provided.

Monthly inspection logs were not provided.

Extension cords were found in the kitchen office.

Monthly inspection logs for carbon monoxide alarms were not provided.

Annual 90 minute power test for emergency lighting was not provided.

Second Semi-Annual Servicing and link size information not provided.

Paperwork for the Second Semi-Annual Hood Cleaning was not provided.

Completed deficiencies report for annual sprinkler inspection was not provided.

Laundry room door will not latch.

Extinguisher in elevator room last serviced in 2021.

Failed to provide documentation showing 30-second monthly activation test of exit signs and emergency lights.

Failed to provide documentation showing 90-minute activation test of exit signs and emergency lights.

Facility failed to provide documentation showing kitchen suppression system technician holds ICC/NAFED certification.

Facility failed to provide documentation showing first semi-annual servicing of 2022 for the kitchen suppression system.

Facility failed to provide documentation showing annual fire door inspection.

Facility failed to provide documentation showing sensitivity testing of smoke detectors.

Facility failed to provide documentation showing annual replacement of fusible links for the kitchen suppression system.

Facility failed to provide documentation showing 4-year inspection of fire/smoke dampers.

Facility failed to maintain electrical outlet box next to room 309 on 3rd floor, wires exposed.

Facility failed to provide 1st semi-annual kitchen hood cleaning for 2022.

Facility failed to provide documentation of annual fire wall inspection; failed to maintain fire walls (various penetrations need caulking, holes in kitchen dinning ceiling, holes in hallway ceiling by kitchen pantry room).

Failed to provide documentation for maintenance; failed to maintain CO detectors in sprinkler control room, basement furnace room, and hallways.

Facility failed to provide documentation for 3-year dry system full flow trip test, annual trip test, 5-year backflow internal pipe test, and quarterly inspections. Sprinkler control room riser pipes blocked and no wrench found in sprinkler head box.

Facility failed to provide documentation of annual inspection of fire-resistance-rated construction (fire wall inspection).

Facility failed to provide documentation showing service technician for fire alarm system holds NICET II or ESA/NTS certification.

Exit routes in basement and by elevator blocked by storage items.

Facility failed to provide documentation showing annual fire door inspection.

Fire department connection located outside of basement, cap missing.

Facility failed to provide documentation showing 4-year inspection of fire/smoke dampers.

Facility failed to provide documentation for quarterly sprinkler inspections.

Facility failed to provide documentation showing annual inspection; fire alarm system is currently yellow tagged.

Emergency light #8 by room 315 did not activate when tested.

Fire alarm panel unlocked and no breaker lock on the fire alarm panel circuit breaker.