Stillwater House

Facility failed to ensure 1 of 2 staff had a background check completed every two years as required.

Facility failed to submit background check authorization within one business day of hire for 1 of 2 staff.

Gas-fired commercial cooking appliances on casters lacked a required restraining device.

Fire-resistance-rated construction penetrations were sealed with unapproved fire foam.

Fire door labels were painted over in Room 3 and the dining room entrance; fire doors were propped open in Room 3.

Facility lacked a hydraulic calculation plate on the fire sprinkler system.

Missing documentation for 3rd Quarter sprinkler inspection, 5-year internal pipe testing, and annual forward flow test.

Kitchen suppression system fuse links rated for 450 degrees Fahrenheit; documentation needed to verify suitability.

Inconsistent documentation for monthly 30-minute load tests of emergency/standby power systems.

Fire drill reports missing start/end times and staff signatures.

Facility failed to conduct quarterly inspections of the fire sprinkler system.

Unsealed penetrations in office ceiling, missing ceiling panel in boiler room, and no record of annual fire resistant rated construction inspection.

Fire damper in boiler room was inoperable (wired open); missing records for fire/smoke damper inspection.

Missing documentation for quarterly inspections, annual confidence test, annual forward flow test, and 5-year inspection report.

Unable to provide documentation showing monthly CO alarm inspections in the last 12 months.

Exit sign above main entrance has incorrect directional arrow.

Failed to provide documentation of 30-second monthly activation tests.

Failed to provide documentation of 90-minute annual power test.

Facility failed to complete state background checks within one business day of hire for 2 of 2 sampled staff.

Facility failed to screen 1 of 3 sampled staff for TB within three days of employment.

Facility failed to ensure 3 of 3 sampled staff completed required continuing education hours.

Staff C did not apply for HCA or NA-C certification within 14 days of hire.

Facility failed to ensure Staff C held required credentials for providing clinical services.

Power strip plugged into another power strip in main office.

Extension cord in supervisors office and incorrect multi adapter in janitor closet.

Cover missing over plug behind refrigerator in dining room.

Missing documentation for first and second semi-annual hood cleaning.

Missing annual inspection documentation of fire-resistance-rated construction.

Unprotected penetration found near resident room 9 by emergency light.

Exit door by resident room 3 will not close and latch.

Multiple missing sprinkler system test records (5-year, 3-year, flow test, quarterly) and system yellow tagged.

Missing documentation for semi-annual servicing and annual replacement of fusible links.

Annual servicing past due and extinguisher next to generator not inspected since 2021.

Missing annual report, sensitivity testing, nuisance log, and alarm test records; system yellow tagged.

Missing documentation for carbon monoxide alarm/detector testing.

Missing emergency/standby power service records and weekly/monthly inspection logs.

4-year fire/smoke damper inspection not performed/documented.

Fire door annual inspection not performed/documented.