Frasier Meadows Health Care Center

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

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.

Gas, Vacuum, and Electrical Systems Deficiencies

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

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

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

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

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

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

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

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Smoke Deficiencies

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

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.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1.Annual report shows that detectors were missed in elevators shaftsNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Elec.. Based on 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 was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacl.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following1. Facility missing multiple monthly generator reports | Battery Conductance | Transfer Times 2. Generator 2022 report stated wiring not installed through conduits and against sharp edges8.1.1 The routin.. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 7.2.1.4.5.11. E/F Hall egress doors take more that 15-lbs of pressure to put in motionNFPA 101 7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to.. Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. Also electrical wiring iaw NFPA 70 (11)1.High altitude orifices needed for dryers2. Daisy chain power cord in FA room NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High A.. Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1. Main hall office fire door not latching NFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exi.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011.Sprinkler escutcheon missing fire alarm room 2.Missing 3 year dry system full trip test report | Testing was conducted May 16, 2023 no report available to review 3.Facility needs additional sprinkler heads in stock in sprinkler head boxNFPA 101: 4.6.12... Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61.Fire drills closer than hour apart during the last 12 months NFPA 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 has .. This survey was conducted on May 08, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This facility is a two (2) story, Type II (111) construction with a protected non-combustible structure with a partial basement area occupied as a parking garage.The first floor is known as the Garden Level and the second floor is known as the Main Level. Each floor is arr..

A recertification survey was conducted from 4/10/24 to 4/16/24. One deficiency was cited. An Emergency Preparedness survey was conducted from 4/10/24 to 4/16/24. No deficiencies were cited. Based on observations, record review and interviews the facility failed to ensure one (#31) of three residents reviewed for pressure-related skin conditions out of 19 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing.Resident #31, who was at risk for developing pressure injuries due to a recent surgery to replace his left hip joint, was admitted to the facility on 3/8/24. According to the facility' s assessment of the resident' s skin on 3/8/24, the resident was admitted without any pressure injuries.The facility implemented a pressure reducing mattress upon the resident' s admission, however, there were no interventions implemented for offloading the resident' s heels, which were at an increased risk for skin breakdown due to the resident' s decrease in mobility following the left hip surgery. On 3/11/24, a left heel blister was observed to the resident' s left heel and a right heel blister developed later that same day. The facility did begin appropriate treatment of the wounds and implemented further interventions to address offloading the resident' s heels after the wounds were identified, however, they failed to implement appropriate interventions of heel booties or an air mattress overlay until after the wounds developed.Despite providing treatment to the wounds after they developed and implementing..

A licensure survey was completed on 4/10/24 to 4/17/24. One deficiency was cited. Based on observations, record review and interviews the facility failed to ensure one (#31) of three residents reviewed for pressure-related skin conditions out of 19 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing.Resident #31, who was at risk for developing pressure injuries due to a recent surgery to replace his left hip joint, was admitted to the facility on 3/8/24. According to the facility' s assessment of the resident' s skin on 3/8/24, the resident was admitted without any pressure injuries.The facility implemented a pressure reducing mattress upon the resident' s admission, however, there were no interventions implemented for offloading the resident' s heels, which were at an increased risk for skin breakdown due to the resident' s decrease in mobility following the left hip surgery. On 3/11/24, a left heel blister was observed to the resident' s left heel and a right heel blister developed later that same day. The facility did begin appropriate treatment of the wounds and implemented further interventions to address offloading the resident' s heels after the wounds were identified, however, they failed to implement appropriate interventions of heel booties or an air mattress overlay until after the wounds developed.Despite providing treatment to the wounds after they developed and implementing further interventions, Resident #31' s wounds continued to worsen. The resident was discharged to the hospital on 3/27/24 for further treatment of the wounds. Once at the hospital, Resident #31' s heel wounds required surgical debridement down to the bone. Due to the facility' s failures to identify upon admission that Resident #31 was at risk for pressure injuries related to his recent hip surgery and the facility' s failure to implement timely interventions to offload and protect the resident' s heels, Resident #31 developed pressure wounds to both of his heels within three days of his admission which resulted in his discharge to the hospital 16 days after the wounds developed for further ..

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 11/06/2023 and 11/12/2023, 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.

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 10/30/2023 and 11/05/2023, 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.