Inspection Reports for
The Cottages of Middleton

.161.04 Designated Smoking Areas: facilities designated smoking area, as specified in policy, is not clearly marked.

.155.01 Relocation Agreements: the facility failed to review and update written relocation/transfer agreements; the newest agreement had the wrong address and was signed by a previous administrator.

.410 Requirements for Emergency Actions and Fire Drills: facility failed to conduct fire drills including evacuation of residents on a bi-monthly basis and at least two at night while residents are sleeping, with a gap from March 2023 to August 2023 with no drills conducted.

.403 Fire and life safety standards: facility did not maintain compliance with NFPA 101, Chapter 33; failed to provide documentation for five-year smoke detector sensitivity testing and quarterly testing of water flow devices of the fire suppression sprinkler system (previously cited 5/3/2023).

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: the facility lacked documentation for annual fire alarm inspections and 5-year smoke detector sensitivity tests, fire extinguishers were not inspected or serviced since 2021 and were not visually inspected monthly, a fire extinguisher was in the red, curtains were hanging in egress paths without flammability documentation, and staff training on the emergency plan was not documented (previously cited 12/17/2021).

.405.04. Fuel-fired heating: the facility could not produce documentation showing fuel-fired heating systems had been inspected, serviced, and cleaned in the past 12 months.

.405.01. Electrical installations and equipment: the facility used daisy-chained extension cords as a replacement for permanent wiring, which is prohibited.

.405.02.b Prohibited applications: a Relocatable Power Tap was plugged in succession to another creating a daisy chain at IT equipment above the freezer in the garage, which is prohibited.

.250.09 Plumbing: water temperature at the resident bathroom sink was 123 degrees.

.300.02 Licensed Nurse: the facility nurse did not document assessment or staging of Resident #4's pressure injury or assess the resident after a urinary tract infection.

.305.02.b Current Medication Orders and Treatment Orders: medications were not given as ordered, including blood pressure medication held incorrectly and missed applications of medications and lotions for Residents #1 and #4.

.330.04.c Resident Care Records: caregivers did not document resident behaviors, nurse notifications, NSA adherence, or PRN medication effectiveness; documentation was completed retrospectively by administrator and nurse.

.335.02 Standard Precautions: the facility did not follow CDC guidelines for mask wearing during the pandemic, with caregivers observed not wearing masks on multiple occasions.

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: no documentation of annual inservice for staff and residents on emergency roles and responsibilities, two delayed egress door systems were not signed as required, and emergency egress lighting testing via remote control would not function to substantiate operation.

.405.03. Telephone: no documentation on the training for qualified staff on the risks associated with oxygen.

.415.05 Automatic Fire Extinguishing System Service and Testing: no documentation for monthly visual inspections of sprinkler system gauges and control valves, only three spare sprinklers in the spare sprinkler box instead of six, and no specialized wrench for replacement or installation of recessed sprinkler heads.

.410.02 Fire Drills: missing fire drills for second shift, first and second quarter 2019.

.250.10 Plumbing: hot water temperatures exceeded the maximum temperature allowed, measured at 124 degrees at the time of the survey.

.220.02 Written Agreement: Resident #4's Admission Agreement was not transparent when it did not document she was being admitted into a secured environment.

.305.03 Resident Health Status: The facility nurse did not document she assessed Resident #5 when she experienced changes in her health condition, including multiple falls and injuries between August and October 2018.