Center at Foresight LLC, the

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Smoke Deficiencies

Provide properly protected cooking facilities.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The building is a three-story, Type II (111) construction without a basement, 53,820 square feet. The facility is divided into two smoke compartments on the first, second, and third floors. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. Emergency power is provided by a diesel-driven generator. The facility is equipped with a piped medical gas system in th.. Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Fire sprinkler system needs to remove grounding cable from the fire sprinkler system 2) The fire sprinkler system is missing general information signageBased on a record review, it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.NFPA 101, 9.7.5 Maintenance and Testing.All automatic sprinkler and standpipe systems required by this Code shall be inspected, test.. Through document review during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Not ProvidedNFPA 996.3.4.1.1Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.6.3.4.1.2Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.6.3.4.1.3Receptacles not listed as hospital-grade a.. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:1) kitchen appliances need cables and casters. 2) need coverage addressed for appliance and nozzle placement NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code unless such installations are approved existing installations, which shall be permitted to be continued in service.NFPA 549.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning .. Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1) The soiled linen room 136 needs to be repaired with fire caulking2) procedure room 161 needs a drywall patch to the 1-hour rated wall3) Need door closure on Salon deemed hazardous area due to the presence of flammable aerosols4) The corridor 158 rated wall needs to be patchedNFPA 10118.3.2.1* Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated.NFPA 1014.5.8 Maintenance. Whenever or .. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) The emergency generator needs battery-powered lightingNFPA 9915.5.1.3 Emergency Generators and Standby Power Systems. Emergency generators and standby power systems, where required for compliance with this code, shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.NFPA 1107.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units loca..

A recertification survey was conducted from 4/24/24 to 4/30/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 4/24/24 to 4/30/24. No deficiencies were cited. Based on observation and interviews, the facility failed to ensure residents received professional standards of care for one (#18) of one resident reviewed for edema care out of 28 sample residents.Specifically, the facility failed to appropriately notify the provider of significant weight changes for Resident #18.Findings include:I. Facility policy The Edema policy, revised March 2024, was provided by the nursing home administrator (NHA). on 4/30/24 at 1:54 p.m.. It documented in pertinent part, "Nurses are to obtain daily weights if ordered by the provider, and nurses are to notify the provider with any changes in edema." The Weight Loss and Interventions policy, revised March 2024,was provided by the NHA on 4/30/24 at 1:54 p.m. It documented in pertinent part, "Nursing staff measures residents' weights on admission and then the next day or as ordered by physician, nurse practitioner, or dietician."III. Resident #18A. Resident StatusResident #18, over the age of 65, was admitted on 2/2/24. According to the April 2024 computerized .. Based on record review and interviews, the facility failed to ensure residents or their representative were aware of the nature and implications of the facility' s arbitration agreement to inform their decision on whether or not to enter into such agreements for five (#10, #38, #96, #194 and #198) of six residents out of 28 sample residents. Specifically, the facility failed to:-Thoroughly explain the arbitration agreement in a form and in a manner the residents and/or resident representatives understood the agreement before signing the arbitration agreement;-Accurately inform residents the arbitration agreement was a binding agreement before the agreement was signed; -Accurately inform residents the agreement could be rescinded by written notice within 90 days of the signing of the agreement; and, -Ensure staff reviewing the arbitration agreement with residents and the residents' representatives understood the components of the agreement.Findings include:I. The arbitration agreementThe Dispute Resolution and Arbitration A..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/19/2023 and 06/25/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.