Bella Vita Health and Rehabilitation Center

Based on observation, the facility failed to maintain oxygen cylinders in a code-compliant and safe manner. Failure to maintain oxygen in a safe and orderly environment could result in injury or death of any staff and residents.

Based on review of the facility Emergency Plan (EP) record review, and staff interview, it was determined the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must include contact information related to staff, entities providing services under arrangement, residents' physicians, next of kin, guardian or custodian, other facilities and volunteers be reviewed and updated at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to the harm to all patients and staff.

Based on a record review and staff interview, it was determined that the facility failed to ensure that its Emergency Preparedness plan included documentation for the emergency and standby power systems. Failure to implement the emergency and standby power systems plan during an emergency could lead to harm of all residents and staff.Â

Based on observation, the facility allowed conflicting signage, chevrons pointing in the wrong direction, on an exit sign above a corridor exit door designated as an exit path. Allowing the use of signage with conflicting information could harm all patients and/or staff needing to utilize the exit in the event of a fire or emergency.

Based on observation, the facility failed to ensure there were no penetrations in the firewall of a hazard room. Failing to maintain the firewall in a hazardous room could cause harm to the patients and/or staff in the area in the event of a fire due to rapid fire travel.

Based on observation, the facility failed to maintain smoke detectors in two locations. Failure to maintain the fire/smoke alarm detectors could cause harm to all staff and residents in the area during an emergency.

Based on observations and interviews, the facility failed to provide automatic sprinkler protection for the attached canopies in three locations around the facility. Failing to provide automatic sprinklers in all areas of the facility could cause harm to all of the residents and/or staff in the area in the event of a fire.

Based on observation, it was determined that the facility failed to maintain the sprinkler system, sprinkler heads, and escutcheon plates, which are part of the entire sprinkler frame and assembly, in several areas of the facility. Failing to maintain the sprinkler heads and escutcheon plates could cause harm to the residents by allowing a fire to spread before the temperature is reached to set off the sprinkler head.

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, potentially harming all patients and/or staff in the affected areas.

Based on observation, the facility failed to fill penetrations in five (5) smoke barriers. Failing to seal penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the entire facility, potentially harming all residents and staff in the area in the event of a fire.

Based on a record review and interviews, the facility failed to provide all required fire drills per NFPA 101. Failing to conduct fire drills in accordance with the life safety code, one per shift per quarter under varied conditions, to familiarize staff with conditions under an actual fire, can result in harm to all residents and/or staff during an actual fire or emergency situation.

Based on observation, it was determined that the facility failed to provide non-combustible ashtrays in all areas where smoking is permitted, and metal containers with self-closing cover devices into which ashtrays can be emptied. Failure to provide non-combustible ashtrays for the proper disposal of cigarette butts and ashes could result harm to all residents and staff in the area in the event of fire.

Violation cited

Violation cited

Violation cited

Violation cited