Weatherly Inn at Lake Meridian, the

Facility failed to provide clear, easy-to-read instructions for staff and visitors on how to exit the secure memory care facility.

Facility failed to implement safe medication systems for 3 residents; medications were prepared in advance and not properly stored in containers with pharmacist-prepared labels.

Combustible storage in Lv4 clean laundry is within 18 inches from sprinkler head.

Combustible storage found blocking safety refuge in all stairwells.

Missing documentation for Annual Sprinkler System report, 3-Year Dry System Full flow trip test, Annual Trip Test, and Annual forward flow test.

Extension cord being used with an appliance in Lv3 kitchen.

Lv3 pass through door will not latch.

Emergency stop is not located outside exterior of the enclosure.

Smoke detector sensitivity report not provided.

Monthly visual inspection of emergency lighting not performed and documented.

Failed to secure hazardous chemicals on a housekeeping cart and stored large ladders in a resident-accessible area.

Failed to ensure 16 of 16 residents in Unit 2 had access to outdoor space and that all 53 residents had independent access to their apartments.

Failed to notify residents, staff, and visitors of a COVID-19 case in the facility.

Air exchange vents in 3 utility closets, 4 linen rooms, and 4 shower rooms were not functioning.

Failed to post weekly menus for 53 residents and did not have a dietary manual available for staff.

Failed to ensure 4 of 9 residents received medications as prescribed and expired medications were found in medication carts.

Fire Alarm room located outside has an unsealed conduit.

Loaded sprinkler heads observed in 2nd floor laundry, 2nd floor dirty laundry, and office in 1st floor main kitchen.

Facility unable to provide documentation for current hood cleaning.

Facility unable to provide documentation for annual fire alarm testing.

Facility unable to provide documentation for twelve planned and unannounced fire drills in the previous 12 months.

Air conditioner plugged into a power strip in the 2nd floor Resident Manager's office.

Facility unable to provide documentation for annual sprinkler test, forward flow test, and 1st quarter sprinkler report.

Combustible materials stored in 2nd floor mechanical room by 401 and 2nd floor laundry mechanical room.

Seven doors (various locations) did not close/latch properly when tested.

Two exit signs (one near 2nd floor office/kitchenette, one in 1st floor kitchenette) did not work when tested.

Dirty sprinkler heads throughout the facility.

Unable to provide kitchen suppression system service reports for past 12 months.

Power strip dangling in the air in the employee break room.

Unsecured oxygen in the oxygen supply room.

Unable to provide CO detector testing documentation for past 12 months.

Missing ceiling tiles in level 3 linen room; wall penetrations in linen room and fire alarm breaker room.

Unapproved heater observed at the reception desk.

No documentation for fire/smoke damper testing.

Extension cords in use at outside patio areas, salon, and plugged into multi-plug adapter at reception.

Missing documentation for generator annual servicing, weekly inspections, and 30-minute full load test.

Unable to provide inventory record for fire-resistant-rated doors.

No record of fire-resistant wall inspection or repairs.

Five specific doors (Designer Closet, Boiler room, Fireside room 1, Clean laundry, Maintenance closet) did not latch/close properly.

Right exit door by the car will not open.

Class K extinguisher in kitchen blocked by carts.

Facility unable to provide documentation for annual and semi-annual hood cleaning.

Unable to provide documentation for 12 planned and unannounced fire drills.

Unable to provide annual and quarterly sprinkler inspection documentation.

Unapproved multi-plug adapter in use at the reception desk.

Fire alarm circuit breaker missing required locking device.

Unable to provide record of annual inspection for fire alarm system.

Facility failed to notify the department of a change in administrator within 10 calendar days of the effective date.

Facility failed to provide safe medication services for one insulin dependent resident; resident's insulin dosage exceeded physician's order.

Facility failed to ensure secured outdoor areas were accessible to residents without staff assistance.

2 of 7 facility staff failed to provide documentation of completed, approved CPR training with hands-on skills demonstration.

Facility used nine electronic plug-in type air fresheners in common areas of the dementia care community that were accessible and posed a risk of harm to residents.

Licensors were unable to locate a publicly posted assisted living license during the entrance tour.

Licensee failed to ensure one staff had a chest X-ray or was medically evaluated for signs and symptoms after a positive TB blood test result.

The licensee failed to ensure two staff were screened for Tuberculosis (TB) as required.

The licensee failed to implement their required respiratory protection program (RPP) policy for five staff.

The licensee failed to ensure one staff had a chest X-ray after a positive test result for a Tuberculosis (TB) skin test.