Brookdale Fishers Landing

The facility failed to implement systems supporting safe medication services. Four residents did not receive medications as prescribed, nasal, optical, and topical medications were not labeled when opened, and expired medications were not disposed of from one facility medication cart, placing residents at risk of harm and medical complications.

Floor 2 dryer cords found unsecured (missing strain protection).

Facility failed to provide annual fire alarm inspection report; fire alarm cover missing in laundry room floor 2 (strobe base).

Facility failed to provide annual fire door inspection report; fire doors found non-compliant due to excessive gaps and failed self-closing devices.

Facility failed to provide annual inspection of fire-resistance-rated construction; hole in fire wall found near corridor gas valve.

Facility failed to provide monthly emergency light testing.

Facility failed to provide semi-annual hood suppression testing.

Facility failed to provide annual fire sprinkler inspection, 5 year internal pipe testing, 3 year dry system full flow trip test, annual trip test, annual forward flow test, 5 year FDC hydro test, and quarterly fire sprinkler inspection.

Facility failed to provide annual emergency light testing.

Facility failed to provide annual inspection of fire resistance-rated construction; hole in ceiling of floor 2 activities area.

Facility failed to provide annual fire alarm inspection report.

Facility failed to provide monthly carbon monoxide detector testing.

Facility failed to provide 4 year fire damper inspection report.

Missing annual, 5-year, 3-year, and quarterly sprinkler system inspections/tests.

Facility failed to provide semi annual hood suppression testing.

Fire doors found with items blocking them; 85% compliance rate noted; excessive gaps and failed self-closing devices.

Facility failed to provide 4-year fire damper inspection report.

Facility failed to conduct fire drills once per shift per quarter.

The facility failed to ensure medications were provided in a safe manner by administering an insulin pen belonging to one resident to a different resident for two residents.

The facility failed to perform required skin checks and showers for Resident 1 as agreed upon in their service plan, resulting in a large, painful, open wound that required hospitalization and surgery.

Facility failed to uphold resident rights for 3 residents; a caregiver took photos/videos of residents' private areas/exposed body parts and shared them in a group text message with staff and former staff.

The facility failed to provide care and services for 1 of 3 sampled residents (R1) as agreed upon in their negotiated service plan, resulting in the resident being found in distress, confused, and soiled in bed after being left unchecked overnight.

The licensee failed to integrate annual assessment information from the resident's representative and department case manager into the personal service plan (NSA) for one resident, resulting in the resident not receiving assessed care needs.

The facility failed to integrate annual assessment information provided by the resident's representative and the department case manager into the development of the resident's Negotiated Service Agreement (NSA), resulting in the resident not receiving necessary care.