Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Life Safety
Deficiencies: 4
May 29, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire safety regulations and related standards.
Findings
The facility failed to clearly mark designated smoking areas, did not properly review and update relocation agreements, failed to conduct required bi-monthly fire drills including night drills, and did not maintain compliance with NFPA 101 fire and life safety standards, including missing documentation for smoke detector sensitivity testing and quarterly testing of fire suppression sprinkler system devices.
Deficiencies (4)
| Description |
|---|
| Facilities designated smoking area, as specified in policy, is not clearly marked. |
| Facility failed to review and update written relocation/transfer agreements; newest agreement had wrong address and was signed by previous administrator. |
| Facility failed to conduct fire drills on a bi-monthly basis including at least two at night while residents are sleeping; gap in drills from March 2023 to August 2023. |
| Facility did not maintain compliance with NFPA 101 fire and life safety standards; missing documentation for five-year smoke detector sensitivity testing and quarterly testing of water flow devices of the fire suppression sprinkler system. |
Report Facts
Fire drills frequency: 6
Fire drills conducted at night: 2
Dates of fire drills: Drills held on 12/6/23 at 7:30pm and 8/21/23 at 6:00pm were not during normal sleeping hours
Relocation agreements reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Madison Thweatt | Administrator | Provided information regarding normal resident sleeping times relevant to fire drill timing |
| Jeremy Wilson | Survey Team Leader | Led the fire life safety and sanitation licensure survey |
Inspection Report
Life Safety
Deficiencies: 7
May 3, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for the facility licensed for three through sixteen residents.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, including lack of documentation for annual fire alarm inspection and testing, missing 5-year sensitivity test for smoke detectors, overdue fire extinguisher inspections, presence of flammable curtains without documentation, lack of staff emergency plan training documentation, missing annual inspection of fuel-fired heating systems, and prohibited use of daisy-chained extension cords as a replacement for permanent wiring.
Deficiencies (7)
| Description |
|---|
| No documentation for annual inspection and testing of the fire alarm system. |
| No documentation for 5-year sensitivity test of smoke detectors. |
| Fire extinguisher by activities room not inspected/serviced since 2021; fire extinguishers not visually inspected monthly; fire extinguisher by resident room #2 was in the 'red'. |
| Curtains hanging in dining room and front entry without documentation of flammability or flame rating. |
| No documentation for periodic or bi-monthly staff training on emergency plan roles and responsibilities. |
| No documentation showing annual inspection, servicing, and cleaning of fuel-fired heating devices and systems in past 12 months. |
| Use of daisy-chained extension cords as replacement for permanent wiring, which is prohibited. |
Report Facts
Facility License Number: RC-1185
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Ellis | Administrator | Named as facility administrator |
| Linda Chaney | Survey Team Leader | Named as survey team leader |
Inspection Report
Life Safety
Deficiencies: 2
Apr 8, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at the facility.
Findings
Two non-core issues were identified: a prohibited application of a Relocatable Power Tap creating a daisy chain, and water temperature at a resident bathroom sink measured at 123 degrees.
Deficiencies (2)
| Description |
|---|
| Relocatable Power Tap (RPT) was plugged in succession to another RPT creating a 'daisy chain', which is prohibited. |
| Water temperature at resident bathroom sink was 123 degrees. |
Report Facts
Water temperature: 123
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Ellis | Administrator | Named as facility administrator |
| Linda Chaney | Survey Team Leader | Named as survey team leader conducting fire life safety and sanitation licensure survey |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 23, 2020
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation at The Cottages of Middleton.
Findings
The facility failed to properly document nursing assessments and medication administration, did not ensure caregivers documented resident behaviors and notifications, and did not follow CDC guidelines for mask-wearing during the pandemic.
Complaint Details
The visit was triggered by a complaint and included a follow-up to verify compliance with health care licensure requirements.
Deficiencies (4)
| Description |
|---|
| The facility nurse did not document assessment or staging of Resident #4's pressure injury and did not assess after a urinary tract infection. |
| Medications were not given as ordered, including blood pressure medication held improperly and missed applications of medications and lotions for Resident #4. |
| Caregivers did not document resident behaviors, notifications to nurses, NSA adherence, or PRN medication effectiveness. |
| Facility did not follow CDC mask-wearing guidelines during the pandemic; caregivers were observed not wearing masks on multiple occasions. |
Report Facts
Medication holds: 11
Missed medication applications: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Ellis | Administrator | Named in relation to documentation of resident care records. |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
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