High Point Village

The facility could not provide documentation for all 12 required planned and unannounced fire drills during the preceding 12 months. Missing drills included first shift quarters 1-4, second shift quarter 1, and third shift quarters 1, 3, and 4.

The fire pump report showed yellow static, and the sprinkler head in the kitchen freezer required replacement.

The first semi-annual servicing report was not provided, and a broken nozzle was observed protecting the deep fryer.

A penetration was observed in the fire wall near room 37.

Annual, semi-annual, smoke detector sensitivity, and monthly single- and multiple-station alarm testing reports were not provided.

No report was provided showing that required fire pump testing had been performed.

Documentation showing that fire/smoke damper inspections had been performed and documented was not provided.

Products in the kitchen freezer and in the first-floor housekeeping room near room 32 were stored within 18 inches of sprinkler heads.

Facility unable to provide documentation of an annual 90-minute battery backup light test within the last 12 months.

The transfer switch room (lower level) does not have emergency battery backup lighting.

Multiple penetrations in the laundry room wall (lower level).

Memory care courtyard exit was blocked by a rock and lacks emergency unlocking signage.

Fire extinguishers in the memory care unit are locked and staff do not have keys.

Facility has not had an annual inspection on the Emergency Responder Radio System.

Laundry room - lower level has multiple penetrations in the wall.

The fire extinguishers in the memory care unit are all locked; staff do not have keys.

The transfer switch room (lower level) does not have emergency battery backup lighting.

The facility was unable to provide documentation for an annual 90-minute test of battery backup lights within the last 12 months.

Resident room 113 has an unapproved cube adapter in use.

Facility has not had an annual inspection on the Emergency Responder Radio System.

The facility was unable to provide their current hood cleaning report for their kitchen hood.

The electrical room on the old side has electrical panels blocked with storage.

The memory care courtyard exit was blocked with a rock and lacked required emergency signage.

The licensee failed to ensure four residents kept all their resident-controlled medications in a locked location.

The licensee failed to ensure one staff who tested positive for Tuberculosis (TB), obtained and followed the recommendation of their health care provider.

Failed to ensure 1 of 1 staff (Staff C) who tested positive for TB received a chest X-ray within seven days and followed health care provider recommendations.

Medicaid Disclosure form was printed in an incorrect font size smaller than the required 14-point font.

Facility failed to ensure 4 of 4 residents kept controlled medications in a locked location, risking unauthorized access.

Failed to document service plans, care needs, interventions, and monitoring requirements for 4 of 9 sampled residents.

Facility failed to ensure 1 staff member who tested positive for TB obtained and followed their healthcare provider's recommendation.

Failed to ensure 1 of 3 care staff (Staff E) completed the two-step TB test within the required time frame.

Inoperable vents found in one resident room, the first-floor laundry room, and the third-floor housekeeping room.

Failed to ensure 1 of 1 caregiver (Staff E) completed HCA certification within 200 days of hire.

Failed to ensure 4 of 4 staff (Staff L, M, N, O) followed proper infection control practices (hand hygiene and glove use) during care services.

Hazardous art and craft supplies were found in unlocked cabinets in the activity room.

Failed to ensure 1 of 1 resident (Resident 7) received medication administration by a licensed nurse or nurse-delegated staff.

First-aid kits were not clearly identified or readily available throughout the facility.

Hot water temperatures in four rooms were not maintained between 105 and 120 degrees Fahrenheit.

Fridge, microwave, and coffee pot plugged into a power strip in the Wellness Center.

No documentation for smoke detector sensitivity test.

No documentation for current kitchen suppression servicing.

The facility is missing fire drills for 1st quarter day shift and 4th quarter swing shift.

No documentation for annual/semi-annual hood cleaning.

Missing documentation for annual and quarterly sprinkler inspections.

Penetration in maintenance office door; large gaps in various fire doors.

Unapproved multi-plug adapters in use in Med room and Resident room 7.

No record of annual fire wall inspection/repairs.

Broken door hardware on the back kitchen exit.

Facility failed to include transmission of fire alarm signals during fire drills.

Sprinkler head obstructions in PPE storage and kitchen cooler.

Extension cords in use on patio, court yard, and in resident room 7.

Painted and loaded sprinkler heads identified, and a bent deflector in the hall.

Facility unable to provide documentation for their last smoke detector sensitivity test.

Found painted sprinkler heads (dining room tables 5 and 12, reception area), loaded sprinkler heads (dining room table 5, dining room outside patio), and a bent sprinkler head deflector in the hall by room 34.