The Cottage

The facility failed to provide an effective system for residents to summon staff. The call light system was located only at the front desk and could not be heard by staff when in other parts of the building, which led to a resident fall.

Two sprinkler heads in kitchen are loaded with debris.

Exit sign by room 123 did not illuminate when tested.

Fire doors failed to latch: Double doors by kitchen and double doors by room 112.

Facility failed to keep dry food in an airtight container; a bin of brown rice was found uncovered in the pantry.

Facility failed to ensure 2 of 6 sampled staff completed required mental health specialty training.

Facility failed to ensure 1 of 6 sampled staff had a TB skin test completed within three days of employment.

Facility failed to ensure 1 of 2 sampled pets had current examinations and immunizations from a licensed veterinarian.

Facility failed to provide a presentable and well-maintained environment for exterior grounds.

Facility failed to maintain safe living conditions, evidenced by loose carpet and garbage bags containing debris outside an exit door, and a thick layer of lint build-up outside the laundry room.

Facility failed to ensure 2 of 6 sampled staff had completed the required training within 120 days of hire.

Facility failed to have the required survey binder posted in the entrance; corrected on-site.

Facility failed to administer medications as prescribed for 4 of 4 sampled residents, including errors in dosing schedules, PRN administration, and documenting required vital signs.

Facility failed to ensure medications were available to be administered in a timely manner for 1 of 4 sampled residents.

The facility failed to ensure residents received prescribed medications and medical monitoring. R4 missed numerous doses of Atorvastatin, Eliquis, Levothyroxine Sodium, Meloxicam, Metoprolol Tartrate, and Montelukast Sodium due to facility-managed medication procurement issues and lack of communication with providers. R4 also missed required COVID-19 outbreak monitoring. Staff documented missed doses as 'awaiting clarification' without actual provider communication. Interviews confirmed this was a systemic issue used to mask medication stock-outs and administrative lapses, leading to negative behavioral changes in the resident.

Facility failed to provide signature pages for each fire drill conducted to verify participation.

Facility failed to provide documentation showing 3-year dry system full flow trip test. Facility failed to maintain sprinkler system, system in yellow status and shall be in normal status.

Facility failed to provide annual inspection report for generator.

Facility failed to maintain oxygen tanks in oxygen rooms; tanks found unsecured.

Complaint regarding broken water pipes investigated. Sprinkler system was down due to a leak; a fire watch was implemented and the system was repaired. No fire occurred, no evacuation was required, and no injuries resulted.

Facility failed to provide documentation for the automatic sprinkler system; 1. Five-year fire department connection hydrostatic test.

Facility failed to inspect portable fire extinguishers monthly.

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

Facility failed to provide documentation showing annual inspection report of the fire alarm system.

Facility failed to provide sensitivity testing documentation and a nuisance log for smoke alarms.

Facility failed to provide documentation showing carbon monoxide alarms are being tested and maintained.

Facility failed to maintain carbon monoxide alarms in the laundry room and hallways.

Facility failed to provide documentation showing 90-minute power test for exits and emergency lighting has been conducted.

Facility failed to provide generator annual inspection report, weekly inspection log, and monthly 30-minute full load test log.

Facility failed to maintain oxygen tanks; tanks were not secured in the oxygen room located by room 117.

Facility failed to provide documentation showing annual inspection of fire doors.

Facility failed to pass three consecutive Fire Marshal inspections between 01/24/23 and 05/30/23, specifically related to fire suppression system sensitivity and missing documentation for five-year hydrostatic testing.