Continuing Care at Wind Crest

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.

Construction Deficiencies

Meet requirements for sections of health care facilities separated by fire resistive construction.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Nutrition and Dietary Deficiencies

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

Egress Deficiencies

Have exits that are accessible at all times.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

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

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 elevators that firefighters can control in the event of a fire.

Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain firewalls in accordance with NFPA 101, 8.3.1.2. Fire foam on penetration. Main electrical room. It is not an approved fire-stopping system.NFPA 101, 8.3.1.2 Fire barriers shall comply with one of the following:(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.(2) The fire.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. The therapy patio needs one motion lock, and the exit sign2. The therapy exit door to the patio needs a sign. NFPA 101 7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.Life Safety Code 19.2.10.1. Means of egress shall have signs in acco.. Based on observations and records review, it was determined that the facility did not have Sprinkler System out-of-service guidance in accordance with NFPA 101 and NFPA 25Fire sprinkler out of service | need correct verbiage NFPA 101, 9.7.6 Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.NFPA 25, 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:(1) T.. Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1. No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually.2. Gfci near sink nurse station kitchen.NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms.6.3.3.2.1 The physical integrity of each .. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart, not at varied timesNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed wit.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility occupies the first floor of a three-story, Type II (222) construction. The facility is protected by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinkled. Floors two (2) and Three (3) are occupied by an Assistant Living (Large Board and Care) occupancy. The facility was constructed in 2013 and is.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.The linen closet pipe needs to be switched to black iron, not CPVC mechanical, and the janitor closet needs to be changed.Painted sprinkler stairwell 1 6.3.6.2 Pipe or tube listed for light hazard occupancies shall be permitted to be installed in ordinary hazard rooms of otherwise light hazard occupancies where the room does not exceed 400 ft2 (37 m2).NFPA 25 5.2.1.1.2 Any sprinkler that shows sign..

A recertification survey was conducted on 8/12/24 to 8/15/24. One deficiency was cited. An Emergency Preparedness survey was conducted from 8/12/24 to 8/15/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were labeled and stored properly according to professional standards in two of five locked cabinets in resident rooms. Specifically, the facility failed to ensure medications were labeled with the date they were opened.Findings include:I. Professional referenceAccording to the manufacturer Astra Zeneca, Symbicort Medication Guide (June 2024), retrieved on 8/19/24 from https://den8dhaj6zs0e.cloudfront.net/50fd68b9-106b-4550-b5d0-12b045f8b184/a4b62ab8-1314- 4583-91b4-294ec239f790/a4b62ab8-1314-4583-91b4-294ec239f790_pi_med_guide_rendition__c.pdf, "Throw away Symbicort when the counter reaches zero or three months after you take Symbicort out of its foil pouch, whichever comes first."According to the manufacturer NovoNordisk, Storage and Travel with Tresiba (June 2024), retrieved on 8/ 19/24 from https://www.mynovoinsulin.com/insulin-products/tresiba/how-to-take-tresiba/flextouch-storage.html, " Storage after use - dispose after eight weeks, even if there is insulin left in the pen or vial and the expiration date has not passed."According to the manufacturer NovoNordisk, Taking Novolog-Insulin Aspart (March 2023), retrieved on 8/ 19/24 from https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html, "Storage after use - kee..