The Cottages of Covington

Deficiency previously cited and now corrected.

Facility failed to provide documentation for 12 months of fire drills; specifically missing 2nd Shift - Quarter 1 and 3.

Missing 5-year FDC hydro testing, deficiencies in annual forward flow test, and buildings A, B, C, and D are in yellow status.

The facility failed to provide information for visitors and external providers on how to exit the secured memory care unit, resulting in delayed departures.

Facility failed to complete an updated assessment for 1 resident despite changes in condition, leading to severe dehydration and pressure wounds.

Cottage C cross corridor C1 did not close / latch properly when tested.

Facility was unable to provide documentation for their last fire/smoke damper testing.

Exit signs were broken / did not work properly in the administration building storage room and Cottage B.

The administration building has open conduits in the IT room.

Facility was unable to provide record of their annual fire wall inspection and/or repairs for all fire-resistant-rated construction.

Facility failed to include transmission of fire alarm signals throughout the facility when conducting fire drills.

Facility was unable to provide documentation showing that 90-minute annual testing of the emergency lighting has been performed in the last 12 months.

Facility was unable to provide documentation for their forward flow test and the 4th quarter sprinkler inspection.

Administration building has open conduits in the IT room.

Facility unable to provide documentation for forward flow test and 4th quarter sprinkler inspection.

Facility failed to include transmission of fire alarm signals throughout the facility when conducting fire drills.

Facility unable to provide record of annual fire wall inspection and/or repairs for all fire-resistant-rated construction.

Facility unable to provide documentation showing 90-minute annual testing of emergency lighting performed in the last 12 months.

Cottage C cross corridor C1 did not close / latch properly when tested.

Exit signs in Administration storage room and Cottage B (B-05) were broken/did not work properly.

Facility unable to provide documentation for last fire/smoke damper testing.

The facility failed to notify Home and Community Service (HCS) when a resident was admitted and hospitalized for over twenty-four hours.

First-aid kits in 3 of 3 cottages (B, C, and D) were not readily available, were locked, or were missing; disaster manual lacked location instructions.

Multiple staff members failed to meet required training/certification standards.

Refrigerator systems in 3 of 3 cottages did not maintain safe food temperatures.

Staff failed to complete required CPR training within 30 days of hire.

Facility failed to protect 43 residents from potential infectious illness, lacked a Medical Test Site Waiver (MTSW) for COVID testing, failed to maintain Respiratory Protection Program records, and staff practiced poor hand hygiene and lacked access to paper towels.

Staff failed to complete required dementia and mental health specialty training within 120 days of hire.

Staff failed to complete initial TB test within three days of employment.

Staff failed to complete 70-hour basic training within 120 days of hire; staff worked unsupervised.

Facility failed to properly monitor and maintain refrigerator temperatures to prevent foodborne illness.

Staff failed to complete 12 hours of required annual continuing education.

Hazardous chemicals and plastic bags were found in unlocked cabinets in 3 of 3 resident cottages, posing a risk to residents with cognitive impairments.

Facility failed to provide mechanical soft diets to 2 residents as specified in their service agreements, placing them at risk of choking/aspiration.