Life Care Center of Tucson

Based on record review and staff interviews, the facility failed to ensure that two residents (#222 and #223) and/or the resident's representative received an accurate and complete Advanced Beneficiary Notice (ABN) when Medicare services terminated. The deficient practice could result in residents not knowing of their potential liability for payment. Findings include: Resident #222 was admitted on December 31, 2023 with diagnosis including urinary tract infection, difficulty walking, muscle weakness, arteritis, hypothyroidism, hyperlipidemia, repeated falls, neuromuscular dysfunction of the bladder, and protein-calorie malnutrition. A review of the admission MDS (minimum data set) dated January 7, 2024 revealed a BIMS (brief interview of mental status) score of 00, suggesting severe cognitive impairment. A review of the advanced beneficiary notification for resident #222 revealed the estimated cost for ongoing care effective on February 2, 2024 would be $345.00 a day. The form further revealed that both option 1 and option 3 had been selected in the area that indicated to check one box only. The directions on the form stated to select only one option. Option 1 noted that the care as listed above, outlining the $345.00 a day fee, was wanted, and option 3 noted that the resident does not want the care as listed above. Option 1 and option 3 are in conflict with one another. ____________________________ Resident #223 was admitted on November 25, 2023 with diagnosis including knee pain, patella fracture, depression, glaucoma, irregular heartbeat, obesity, osteoarthritis, breast cancer and spinal stenosis. A review of the 5-day MDS (minimum data set) dated November 29, 2023 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact. A review of the advanced beneficiary form for resident #223 revealed that the estimated cost, to the resident, beginning December 05, 2024 would be $345.00 a day. The 'options-section' of the form denoting that only one box should be checked revealed that no boxes were checked, leaving ambiguity as to whether resident #223 was opting to continue or not continue with services past December 05, 2023. _____________________________ An interview was conducted on July 16, 2024 at 3:13 P.M. with staff #112 (Social Services Director). Staff #112 stated that she believed the advanced beneficiary notification (ABN) was always required for each resident when they are running out of Medicare days of service. Staff #112 stated that only one box should be checked for those sections explicitly stating "check one box" and that this section is required to be completed. Staff #112 reviewed the ABN for resident #223 and stated that a check-box should have been selected, but had not. Staff #112 reviewed the ABN for resident #222 and stated that only one box should have been checked not 2, as observed on the form. Staff #112 stated that the risk would include, that if the form was incorre

Based on observation, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs of 14 residents (#4, #5, #8, #11, #20, #25, #34, #35, #41, #42, #43, #48, #56, and #167). The deficient practice could result in the resident's room not having a homelike and comfortable environment. The facility census was 58 and the sample was 14. Findings include: On the morning of July 15, 2024, between the hours of 6:45 a.m. to 7:00 a.m., surveyors experienced a notable difference in temperature perceived and felt when entering the facility. The temperature felt uncomfortably warm. During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at approximately 6:45 a.m., staff #33 mentioned that the generator did not kick in properly during the power outage yesterday evening. This resulted in the cooling tower (chiller) not activating to cool down the temperature in the facility. Staff #33 stated that the chiller is in the process of kicking in but will take approximately 4 hours to cool down the facility. An observation of the residents' areas was conducted on July 15, 2024 starting at approximately 7:15 a.m. There was no evidence that rooms were being tested for ambient temperature by the staff. This was despite the residents' areas being noticeably and feeling warm/uncomfortable. Regarding Resident #4: -Resident #4 was admitted to the facility on June 9, 2024 with diagnoses that included fracture of the lower end of the right femur, pain in right knee, chronic kidney disease, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment dated June 16, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. The assessment also revealed that the resident was dependent for transfers. The MDS indicated that the resident uses a walker as a mobility device. During an interview conducted with the resident on July 15, 2024 at 8:23 a.m., the resident stated that last night they had no power and that she was uncomfortable. An observation was conducted of the resident's room on July 15, 2024 at 8:23 a.m. There was a notable warm temperature in the room. Regarding Resident #5: -Resident #5 was admitted to the facility on June 28, 2023 with diagnoses that included pressure ulcer of sacral region, osteoporosis, hypertension, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated April 5, 2024 revealed that the resident has modified independence pertaining to decisions regarding tasks of daily life. The assessment also indicated that the resident required substantial assistance for chair to bed transfers, and sit to stand activities. The MDS also noted that the resident uses a wheelchair as a mobility device. During an interview conducted on June 15, 2024 at 8:19 a.m., the resident responded "Si" whe

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to implement and maintain an effective training program for annual training: abuse, resident rights, infection control, dementia training, and emergency preparedness for multiple staff (#50, #26, #43, #54, #38, #59, #32 and #110). Findings include: Review of the employee records for a registered nurse (RN/staff #50) revealed that abuse training was completed on June 15, 2022, completed resident rights on February 27, 2023, infection control training on June 15, 2022, and there was no documentation for emergency preparedness. -Review of the employee records for (RN/staff #26) revealed that abuse training was completed on October 6, 2022, resident rights completed on March 31, 2023, infection control completed on January 27, 2023, and emergency preparedness was competed on January 27, 2023. -Review of the employee record for Licensed practical nurse (LPN/staff #43) revealed that abuse training was completed March 9, 2022, resident rights completed on May 25, 2022, infection control completed May 31, 2022, and there was no documentation for emergency preparedness. -Review of the employee record for (LPN/staff #54) revealed that abuse training was completed on January 2, 2023, resident rights was completed on January 2, 2023, infection control was completed on February 20, 2023, dementia care January 3, 2023, and there was no documentation for emergency preparedness. -Review of the employee record for a Certified nursing assistant (CNA/staff #38) revealed that abuse training completed on October 18, 2022, resident rights October 18, 2022, infection control June 20, 2022, dementia training completed on October 18, 2022, and emergency preparedness was not attempted. -Review of the employee records for The Director of nursing (DON/staff #59) revealed that abuse training was completed on June 29, 2022, resident rights training was not attempted, infection control was not completed, emergency preparedness was not attempted. -Review of the employee records for the Maintenance Director (staff #32) revealed that abuse training, resident rights, infection prevention, and dementia care were not attempted. -Review of the employee records for Administrator (staff #110) revealed no documentation for abuse training, resident rights was not attempted, infection control was not attempted, and emergency preparedness not attempted. An interview was conducted on July 16, 2024 at 1:56 p.m. with the human resources accounting clerk (staff #73), who stated the corporate office usually sends an email when training needs to be done. She stated that all staff, including the Administrator, are required to complete emergency preparedness, resident rights, abuse, infection control, and dementia training annually and the training are due based on the the staff's date of hire. An interview was conducted on July 16, 2024 at 3:33 p.m. with (staff #110), who stated that all

Based on employee records, staff interviews, and the facility policy and procedures, the facility failed to ensure two staff (#110 and #4) had fingerprint clearance cards. Findings include: Review of the employee record revealed that staff #110 was hired on January 8, 2024 as the Executive Director. It did not reveal a fingerprint clearance card. -Review of the employee record revealed that staff #4 was hired on February 29, 2024 for the position of maintenance assistant. It also revealed an application for a fingerprint clearance card dated April 14, 2024. During an interview conducted on July 16 2024 at 1:56 p.m. with human resource personnel/accounting clerk (staff #73), ten employee records were reviewed. Two (#4 and #110) out of ten employees did not have a fingerprint clearance card. She stated that staff #4 was hired on February 29, 2024 and applied for his fingerprint clearance care on April 14, 2024. She stated that in April 2024, all staff had to have a fingerprint clearance card and prior to that date only only nurses and certified nursing assistants (CNAs) had a fingerprint clearance card to work in the facility. She stated that staff #4's job requires him to go into the residents rooms. She reviewed the employee record for staff #110 and stated that she doesn't have a fingerprint clearance card. An interview was conducted on July 17, 2024 at 11:19 a.m. with the Director of Nursing (DON. /staff #59), who stated that the maintenance assistant should probably have a fingerprint clearance card. She stated that he does go into the residents' rooms and comes into contact with the them. She stated that the fingerprint clearance card is to ensure the staff doesn't have anything outstanding and/or and inappropriate background. It is to ensure the safety of the residents. The facility policy, "Background and Drug Screening Checklist, Addendum - State Specific Requirements " revised September 28, 2023 states that all candidates in Arizona must have a valid fingerprint clearance card or apply for a fingerprint clearance care within twenty working days of employment.

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one staff (#110) was free of tuberculosis (TB) prior to working in the facility. Findings include: Staff # was hired as the Administrator (staff #110) for the facility on January 8, 2024, During an interview conducted on July 16, 2024 at 1:56 p.m. with the accounting clerk/human resources personnel (staff #73), she stated that (staff #110) did not provide a current TB test for herself. She stated that the Executive Director is probably supposed to have a TB test prior to working in the building. She stated that the reason for testing is to prevent the risk of TB spreading throughout the building. An interview conducted on July 17, 2024 at approximately 9:50 a.m. with the (staff #110), who stated that she did not have a tuberculosis test prior to working in the facility. She stated that she was tested yesterday, July 16, 2024, and the test results had not been read. An interview was conducted on July 17, 2024 at 11:19 a.m. with the Director of Nursing (DON. /staff #59), who stated that when a person is hired, he/she is required to show a test result for TB is negative prior to working in the facility. She stated that the administrator (staff #110) walks the floors of the building and should do daily. She doesn't interact directly with residents, but follows up with residents as needed. She stated that staff #110 can come into contact with residents when she is walking the halls. The facility policy, "Tuberculosis - Testing and Screening" revised June 28, 2024 states that the facility will evaluate each associate and volunteer for tuberculosis in accordance with current CDC guidelines, unless more stringent guidance is provided by local or state regulation. New associates or volunteers who have been made a conditional offer shall be screened for presence of infection through the following measures; pre-placement risk assessment and symptom evaluation and the facility should also perform skin test for M. Tuberculosis using the Mantoux TST skin test.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that initial and ongoing weights were conducted for one resident (Resident #36). The deficient practice could result in a change of condition not being assessed and monitored. Findings include: Resident #36 was admitted to the facility on February 8, 2024 with diagnoses that included anoxic brain damage, Parkinson's disease and chronic respiratory disease. Review of the clinical record revealed that the resident weighed 187 pounds on February 9, 2024. Review of the nutritional assessment dated February 9, 2024 revealed that the resident was malnourished. The care plan dated February 22, 2024 revealed that the resident was at risk for weight fluctuation related to dysphagia and anoxic brain injury. Interventions included eternal feeding as ordered and weight as per the facility policy. The minimum data set (MDS) dated February 27, 2024 included a staff assessment for mental status score of 2 indicating the resident had moderate cognitive impairment. The clinical record revealed that the resident weighed 168.6 pounds on June 4, 2024 and 167.4 pounds on July 2, 2024. An interview was conducted on July 17, 2024 at 10:07 a.m. with a Registered Dietician (staff #66), who stated that a nutritional assessment is done when residents are admitted and all residents are supposed to be weighed. He stated that resident #36 was not weighed when he was admitted to the facility and the weight documented in the clinical record was taken from the weight documented in the hospital transfer records. He also stated that the resident should have been weighed monthly as per the facility policy in order to assess and monitor weight loss, fluctuations, fluid shifts, and if a weight change has occurred, so the root cause can be determined. He stated that there is a risk of developing malnutrition and/or congestive heart failure (CHF) fluid retention not being recognized if weights are not being monitored. An interview conducted on July 17, 2024 at 11:15 a.m. with the Director of Nursing (DON/staff #59), who stated that the facility policy states that all residents are supposed to be weighed weekly for the first four weeks and then monthly. The reason for weighing the resident is to check for significant weight loss or gain. She stated that when the resident was admitted, the certified nursing assistant (CNA) should take the resident's initial weight and should not use the recorded weight from the hospital records because the weight may not be accurate. She stated that they just recently talked about weighing hospice patients, and all residents should be weighed. The facility addendum to the Lippincott procedure revised August 21, 2023 states that measuring a patient's weight is part of a routine admission to a health care facility. An accurate record of the patient's weight is essential for calculating dosages of drugs, fluid maintenance, anesthetics, and contras

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#6) received assistance with bathing. The deficient practice could result in poor hygiene and skin infections. Findings include: Resident #6 was admitted to the facility on June 8, 2022 and readmitted on April 23, 2024 with diagnoses that included a anxiety, depression, unspecified protein-calorie malnutrition, and a personal history of venous thrombosis and embolism. The care plan for activities of daily living (ADLs) dated March 25, 2024 revealed that the resident has an ADL self-care performance deficit related to weakness and decreased mobility due to acute kidney failure (AKF), pressure ulcer (PU), seizures (s/z) and depressive disorder (d/o). Interventions included that the resident requires assistance by staff with bathing/showering as necessary. The minimum data set (MDS) dated April 30, 2024 included a brief interview for mental status score of 12 indicating the resident was cognitively intact. It also revealed that the resident was dependent on assistance with showers/bathing. Review of the shower/bathing task sheet revealed that the resident was schedule to bath on Monday and Thursday evenings. Review of the shower/bathing task sheet dated April 2024 revealed: -Thursday, April 4, 2024, bathing was completed. -Thursday, April 11, 2024, bathing was refused. -Thursday, April 25, 2024, activity did not occur. Review of the skin care alert form revealed the following directions: Complete this form dally. While assisting the resident with self-care (bathing, toileting. dressing, Etc.), document the presence of any areas of concern or changes in skin, including: redness, bruising, surgical wounds, drainage. rashes, blisters, etc. Use side two to document detail and indicate current strategies to prevent pressure ulcer/injuries. Review of the skin care alert forms from April 2024 through June 2024 revealed one form dated April 15, 2024 with the documention of a bed bath being completed. Review of the shower/bathing task sheet dated May 2024 revealed: -Friday, May 3, 2024, activity did not occur. -Monday, May 6, 2024, bathing was completed. -Thursday, May 9, 2024, activity did not occur. -Monday, May 13, 2024, activity did not occur. -Monday, May 20, 2024, activity did not occur. -Thursday, May 23, 2024, activity did not occur. Review of the shower/bathing task sheet dated June 2024 revealed: -Friday, June 14, 2024, activity did not occur. -Monday, June 17, 2024, bathing was completed. -Thursday, June 20, 2024, bathing was completed. -Monday, June 24, 2024, bathing was completed. -Thursday, June 27, 2024, bathing was completed. Review of the shower task sheet dated July 2024 revealed bathing only one time during the week of July 4, 2024. No bathing was documented on the task sheet from July 5, 2024 through July 15, 2024 and no refusals were documented. During an interview conducted on July 16, 2024 at 12:23 p.m. wit

Based on record review and staff interviews, the facility failed to ensure that two residents (#222 and #223) and/or the resident's representative received an accurate and complete Advanced Beneficiary Notice (ABN) when Medicare services terminated. Findings include: Resident #222 was admitted on December 31, 2023 with diagnosis including urinary tract infection, difficulty walking, muscle weakness, arteritis, hypothyroidism, hyperlipidemia, repeated falls, neuromuscular dysfunction of the bladder, and protein-calorie malnutrition. A review of the admission MDS (minimum data set) dated January 7, 2024 revealed a BIMS (brief interview of mental status) score of 00, suggesting severe cognitive impairment. A review of the advanced beneficiary notification for resident #222 revealed the estimated cost for ongoing care effective on February 2, 2024 would be $345.00 a day. The form further revealed that both option 1 and option 3 had been selected in the area that indicated to check one box only. The directions on the form stated to select only one option. Option 1 noted that the care as listed above, outlining the $345.00 a day fee, was wanted, and option 3 noted that the resident does not want the care as listed above. Option 1 and option 3 are in conflict with one another. ____________________________ Resident #223 was admitted on November 25, 2023 with diagnosis including knee pain, patella fracture, depression, glaucoma, irregular heartbeat, obesity, osteoarthritis, breast cancer and spinal stenosis. A review of the 5-day MDS (minimum data set) dated November 29, 2023 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact. A review of the advanced beneficiary form for resident #223 revealed that the estimated cost, to the resident, beginning December 05, 2024 would be $345.00 a day. The 'options-section' of the form denoting that only one box should be checked revealed that no boxes were checked, leaving ambiguity as to whether resident #223 was opting to continue or not continue with services past December 05, 2023. _____________________________ An interview was conducted on July 16, 2024 at 3:13 P.M. with staff #112 (Social Services Director). Staff #112 stated that she believed the advanced beneficiary notification (ABN) was always required for each resident when they are running out of Medicare days of service. Staff #112 stated that only one box should be checked for those sections explicitly stating "check one box" and that this section is required to be completed. Staff #112 reviewed the ABN for resident #223 and stated that a check-box should have been selected, but had not. Staff #112 reviewed the ABN for resident #222 and stated that only one box should have been checked not 2, as observed on the form. Staff #112 stated that the risk would include, that if the form was incorrectly completed, it would make the form invalid. Staff #112 stated that these forms were completed inacc

Based on observation, a staff interview, and the facility policy and procedures, the facility failed to ensure that the daily staff posting included the correct information. Findings include: On July 14, 2024 at approximately 9:00 a.m. the daily staff posting was observed hanging on the wall just to the left of the reception desk. The information observed on the posting was: -July 12, 2024 -census 60 -number of each type of staff for each shift -the total hours scheduled for each type of staff for each shift -the actual hours worked was not completed During this time the Director of Nursing (DON/staff #59) approached and removed the daily staff posting dated July 12, 2024 and stated that she was just about to the change it. Review of the facility documentation revealed that the census was 58 on July 14, 2024. An interview was conducted on July 17, 2024 at 11:30 a.m. with the (DON/staff #59), who stated that the Central Supply Director/staffing coordinator (staff #95) is responsible for completing daily staff posting and works Monday through Friday. She stated that staff #95 prepares the daily staff postings for the weekend and the weekend receptionist is supposed to switch them out. She stated that the posting is for visitors and residents to see how many staff are available in the building. The facility policy, "Facility Staffing Posting" revised December 13, 2023 states that the facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors. The data should be clear, readable, up to date and current. When listing the total number of staff and actual hours worked, the facility is required to reflect staff absences on each shift that occur due to callouts or illness. The nurse staffing data needs to be posted on a daily basis at the beginning of each shift. The required information that needs to be posted includes: I. Facility name 2. Current date 3. Resident census 4. Total number of staff and actual hours worked per shift for: a. Registered Nurses b. Licensed Nurses c. Certified Nurse Aides

Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored at safe temperatures in accordance with professional standards. This deficient practice could result in placing residents at risk for food-borne illnesses. The facility census was 58. Findings include: During an initial observation of the kitchen, conducted at 8:25 a.m. on July 14, 2024 with staff #15. In the walk-in refrigerator, the thermometers both inside and out registered a temperature displaying 45 degrees Fahrenheit (F). Inside the refrigerator were various food items including milk, eggs, yogurt, meat, cheese, and dressings. Staff #15 stated the temperatures are recorded on the log twice daily, morning and evening. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 14, 2024 was recorded at 36F. The evening temperature was recorded at 40F. The log includes a critical limit (CL) for temperature at 40F on the high end, and revealed that in the event of a temperature not within the required range, to notify the Director of food services or maintenance immediately. During a kitchen observation conducted on July 15, 2024 at 10:12 a.m. of the same walk-in refrigerator, the external thermometer and internal thermometer registered a temperature displaying 42F. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 37F. The evening temperature was recorded at 40F. During a kitchen observation conducted on July 16, 2024 at 9:30 a.m. of the same walk-in refrigerator, the external thermometer registered a temperature displaying 50F. The internal thermometer registered a temperature displaying 44F. A second observation was made on July 16, 2024 at 11:50 a.m. The external thermometer again showed a temperature displaying 50F, and the internal thermometer displayed a temperature of 44F. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 38F. The evening temperature had not been recorded yet. An interview was conducted on July 16, 2024 at 12:35 p.m. with a cook (kitchen staff #40). The cook stated that most of the foods served for meals are stored in the walk-in refrigerator, including prep stuff for the next day, thawing meat, dairy and milk, as well as cottage cheese. The cook also stated that left overs are also stored in the same walk-in. The cook stated that temps in the walk-in need to be 39F or below, and that temperatures are recorded using the outside thermometer twice daily in the monthly log. An interview was conducted on July 16, 2024 at 12:44 p.m. with the Registered Dietician and Kitchen Manager (RD/kitchen staff #66). The RD stated that temperatures need to be under 40F in the walk-in or it puts the food at risk of causing food-borne illness such a botulism. The RD stated that all refrigerated items used in the facility

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one staff (#110) was free of tuberculosis (TB) prior to working in the facility. The deficient practice could result in residents being infected with tuberculosis. Findings include: Staff # was hired as the Administrator (staff #110) for the facility on January 8, 2024, During an interview conducted on July 16, 2024 at 1:56 p.m. with the accounting clerk/human resources personnel (staff #73), she stated that (staff #110) did not provide a current TB test for herself. She stated that the Executive Director is probably supposed to have a TB test prior to working in the building. She stated that the reason for testing is to prevent the risk of TB spreading throughout the building. An interview conducted on July 17, 2024 at approximately 9:50 a.m. with the (staff #110), who stated that she did not have a tuberculosis test prior to working in the facility. She stated that she was tested yesterday, July 16, 2024, and the test results had not been read. An interview was conducted on July 17, 2024 at 11:19 a.m. with the Director of Nursing (DON. /staff #59), who stated that when a person is hired, he/she is required to show a test result for TB is negative prior to working in the facility. She stated that the administrator (staff #110) walks the floors of the building and should do daily. She doesn't interact directly with residents, but follows up with residents as needed. She stated that staff #110 can come into contact with residents when she is walking the halls. The facility policy, "Tuberculosis - Testing and Screening" revised June 28, 2024 states that the facility will evaluate each associate and volunteer for tuberculosis in accordance with current CDC guidelines, unless more stringent guidance is provided by local or state regulation. New associates or volunteers who have been made a conditional offer shall be screened for presence of infection through the following measures; pre-placement risk assessment and symptom evaluation and the facility should also perform skin test for M. Tuberculosis using the Mantoux TST skin test.

Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff. Findings include: Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage. The following are staff interviews: Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility arriving at 1845 hours. Staff # 32 further stated that the facility was dark and the staff were panicking. Staff # 32 stated that he began troubleshooting and found that the main breaker for the facility had popped and that he reset it. Staff #32 further stated that it took approximately one hour to troubleshoot and that the generator was manually started between 1945 and 2000 hours. Staff # 32 stated that the chillers were not active as they drew too much voltage. Staff # 32 stated that When he arrived at the facility on July 15, 2024, he was unaware that the circular pumps were off. Staff # 32 stated that he later learned that staff #33 had bypassed the circular pumps because he had turned the alarm had been turned off. Staff# 32 stated that had the alarm been on he would have known there was an issue with the circular pumps. Staff #32 stated that at 0700 hours on July 15, 2024, they had to go through the facility and reset all of the AC units. Monday, July 15, 2024, at approximately 1010 hours an interview was conducted with staff # 69, RN unit nurse. Staff # 69 stated that the electricity went out between 1820 and 1830 hours on July 14, 2024. The residents that were on oxygen concentrators had to be switched to O2 tanks due to the electricity being out. Staff #69 stated that the alarm did not go off last night regarding the generator. Staff # 69 further stated that with the electricity being out he knew that the doors needed to be watched to prevent any elopement. Staff # 69 stated that if the resident rooms are hot they should begin moving residents immediately however, if the electricity is out the elevators would not work so they would not be able to move the residents. Staff # 69 stated that he was assuming the generator would kick in right away, but that it did not, and this is why they called maintenance. Monday, July 15, 2024, at approximately 1048 hours, St

Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents: Findings include: Regarding safe environment: During the initial walk-through observation of the facility conducted on July 14, 2024 at 10:11 a.m., the following was observed: - Doorway frame missing in room #2100, light brown paint is peeling, exposing the green pain underneath. It felt rough to the touch. - Corner handrail by room #2117 was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Second floor nurse's station corner had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Corner handrail on the second floor by the stairway had 4 screws sticking out. Additionally, the handrail had gouges and was sharp/rough to the touch In a follow-up wall-through conducted on July 17, 2024 at 8:53 a.m., the following was observed: - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. This included shower doorframe. - Corner handrail by room #2117 was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Corner rail by soiled utility on the second floor had a metal brace that was slightly sticking out. - Second floor nurse's station corner still had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Below the handrail next to linen room on the second floor by room #2133 had a metal brace on the wall corner that is slightly sticking out. That same corner has pieces of the wall corner with severe gouges that is rough/sharp to the touch. - Corner entry to wall to room #2137 had a metal brace that was coming off the wall and the wall corner had severe gouges that was rough/sharp to the touch. - Inside entry wall right hand side in room #2133 has long deep gouges on the lower wall above the baseboard. - Corner handrail on the second floor by the stairway no longer had the 4 screws sticking out. However, the handrail had gouges and was sharp/rough to the touch. An interview with a Registered Nurse (RN/staff #50) was conducted on July 17, 2024 at 8:29 a.m. Staff #50 stated the process for submitting work orders is that they can either use the book, the app, or call the emergency number for maintenance for whoever is on call. When asked about the overall status of the hallways/residents' living area, the RN noted that the place could use a lot of TLC (tender loving care). Staff #50 noted that to their knowledge

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to implement and maintain an effective training program for annual training: abuse, resident rights, infection control, dementia training, and emergency preparedness for multiple staff (#50, #26, #43, #54, #38, #59, #32 and #110). The deficient practice could impact the safety, rights, and care provided to residents. Findings include: Review of the employee records for a registered nurse (RN/staff #50) revealed that abuse training was completed on June 15, 2022, completed resident rights on February 27, 2023, infection control training on June 15, 2022, and there was no documentation for emergency preparedness. -Review of the employee records for (RN/staff #26) revealed that abuse training was completed on October 6, 2022, resident rights completed on March 31, 2023, infection control completed on January 27, 2023, and emergency preparedness was competed on January 27, 2023. -Review of the employee record for Licensed practical nurse (LPN/staff #43) revealed that abuse training was completed March 9, 2022, resident rights completed on May 25, 2022, infection control completed May 31, 2022, and there was no documentation for emergency preparedness. -Review of the employee record for (LPN/staff #54) revealed that abuse training was completed on January 2, 2023, resident rights was completed on January 2, 2023, infection control was completed on February 20, 2023, dementia care January 3, 2023, and there was no documentation for emergency preparedness. -Review of the employee record for a Certified nursing assistant (CNA/staff #38) revealed that abuse training completed on October 18, 2022, resident rights October 18, 2022, infection control June 20, 2022, dementia training completed on October 18, 2022, and emergency preparedness was not attempted. -Review of the employee records for The Director of nursing (DON/staff #59) revealed that abuse training was completed on June 29, 2022, resident rights training was not attempted, infection control was not completed, emergency preparedness was not attempted. -Review of the employee records for the Maintenance Director (staff #32) revealed that abuse training, resident rights, infection prevention, and dementia care were not attempted. -Review of the employee records for Administrator (staff #110) revealed no documentation for abuse training, resident rights was not attempted, infection control was not attempted, and emergency preparedness not attempted. An interview was conducted on July 16, 2024 at 1:56 p.m. with the human resources accounting clerk (staff #73), who stated the corporate office usually sends an email when training needs to be done. She stated that all staff, including the Administrator, are required to complete emergency preparedness, resident rights, abuse, infection control, and dementia training annually and the training are due based on the the staff's date of hire. An inte

Based on observation, a staff interview, and the facility policy and procedures, the facility failed to ensure that the daily staff posting included the correct information. Findings include: On July 14, 2024 at approximately 9:00 a.m. the daily staff posting was observed hanging on the wall just to the left of the reception desk. The information observed on the posting was: -July 12, 2024 -census 60 -number of each type of staff for each shift -the total hours scheduled for each type of staff for each shift -the actual hours worked was not completed During this time the Director of Nursing (DON/staff #59) approached and removed the daily staff posting dated July 12, 2024 and stated that she was just about to the change it. Review of the facility documentation revealed that the census was 58 on July 14, 2024. An interview was conducted on July 17, 2024 at 11:30 a.m. with the (DON/staff #59), who stated that the Central Supply Director/staffing coordinator (staff #95) is responsible for completing daily staff posting and works Monday through Friday. She stated that staff #95 prepares the daily staff postings for the weekend and the weekend receptionist is supposed to switch them out. She stated that the posting is for visitors and residents to see how many staff are available in the building. The facility policy, "Facility Staffing Posting" revised December 13, 2023 states that the facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors. The data should be clear, readable, up to date and current. When listing the total number of staff and actual hours worked, the facility is required to reflect staff absences on each shift that occur due to callouts or illness. The nurse staffing data needs to be posted on a daily basis at the beginning of each shift. The required information that needs to be posted includes: I. Facility name 2. Current date 3. Resident census 4. Total number of staff and actual hours worked per shift for: a. Registered Nurses b. Licensed Nurses c. Certified Nurse Aides

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that initial and ongoing weights were conducted for one resident (Resident #36). Findings include: Resident #36 was admitted to the facility on February 8, 2024 with diagnoses that included anoxic brain damage, Parkinson's disease and chronic respiratory disease. Review of the clinical record revealed that the resident weighed 187 pounds on February 9, 2024. Review of the nutritional assessment dated February 9, 2024 revealed that the resident was malnourished. The care plan dated February 22, 2024 revealed that the resident was at risk for weight fluctuation related to dysphagia and anoxic brain injury. Interventions included eternal feeding as ordered and weight as per the facility policy. The minimum data set (MDS) dated February 27, 2024 included a staff assessment for mental status score of 2 indicating the resident had moderate cognitive impairment. The clinical record revealed that the resident weighed 168.6 pounds on June 4, 2024 and 167.4 pounds on July 2, 2024. An interview was conducted on July 17, 2024 at 10:07 a.m. with a Registered Dietician (staff #66), who stated that a nutritional assessment is done when residents are admitted and all residents are supposed to be weighed. He stated that resident #36 was not weighed when he was admitted to the facility and the weight documented in the clinical record was taken from the weight documented in the hospital transfer records. He also stated that the resident should have been weighed monthly as per the facility policy in order to assess and monitor weight loss, fluctuations, fluid shifts, and if a weight change has occurred, so the root cause can be determined. He stated that there is a risk of developing malnutrition and/or congestive heart failure (CHF) fluid retention not being recognized if weights are not being monitored. An interview conducted on July 17, 2024 at 11:15 a.m. with the Director of Nursing (DON/staff #59), who stated that the facility policy states that all residents are supposed to be weighed weekly for the first four weeks and then monthly. The reason for weighing the resident is to check for significant weight loss or gain. She stated that when the resident was admitted, the certified nursing assistant (CNA) should take the resident's initial weight and should not use the recorded weight from the hospital records because the weight may not be accurate. She stated that they just recently talked about weighing hospice patients, and all residents should be weighed. The facility addendum to the Lippincott procedure revised August 21, 2023 states that measuring a patient's weight is part of a routine admission to a health care facility. An accurate record of the patient's weight is essential for calculating dosages of drugs, fluid maintenance, anesthetics, and contrast agents; calculating tidal volume in patients requiring mechanical ventilation; assessing the

Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored at safe temperatures in accordance with professional standards. The facility census was 58. Findings include: During an initial observation of the kitchen, conducted at 8:25 a.m. on July 14, 2024 with staff #15. In the walk-in refrigerator, the thermometers both inside and out registered a temperature displaying 45 degrees Fahrenheit (F). Inside the refrigerator were various food items including milk, eggs, yogurt, meat, cheese, and dressings. Staff #15 stated the temperatures are recorded on the log twice daily, morning and evening. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 14, 2024 was recorded at 36F. The evening temperature was recorded at 40F. The log includes a critical limit (CL) for temperature at 40F on the high end, and revealed that in the event of a temperature not within the required range, to notify the Director of food services or maintenance immediately. During a kitchen observation conducted on July 15, 2024 at 10:12 a.m. of the same walk-in refrigerator, the external thermometer and internal thermometer registered a temperature displaying 42F. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 37F. The evening temperature was recorded at 40F. During a kitchen observation conducted on July 16, 2024 at 9:30 a.m. of the same walk-in refrigerator, the external thermometer registered a temperature displaying 50F. The internal thermometer registered a temperature displaying 44F. A second observation was made on July 16, 2024 at 11:50 a.m. The external thermometer again showed a temperature displaying 50F, and the internal thermometer displayed a temperature of 44F. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 38F. The evening temperature had not been recorded yet. An interview was conducted on July 16, 2024 at 12:35 p.m. with a cook (kitchen staff #40). The cook stated that most of the foods served for meals are stored in the walk-in refrigerator, including prep stuff for the next day, thawing meat, dairy and milk, as well as cottage cheese. The cook also stated that left overs are also stored in the same walk-in. The cook stated that temps in the walk-in need to be 39F or below, and that temperatures are recorded using the outside thermometer twice daily in the monthly log. An interview was conducted on July 16, 2024 at 12:44 p.m. with the Registered Dietician and Kitchen Manager (RD/kitchen staff #66). The RD stated that temperatures need to be under 40F in the walk-in or it puts the food at risk of causing food-borne illness such a botulism. The RD stated that all refrigerated items used in the facility are stored in that walk-in, including dairy, cheese, eggs and leftovers. The RD further sta

Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents. Findings include: Regarding safe environment: During the initial walk-through observation of the facility conducted on July 14, 2024 at 10:11 a.m., the following was observed: - Doorway frame missing in room #2100, light brown paint is peeling, exposing the green pain underneath. It felt rough to the touch. - Corner handrail by room #2117 was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Second floor nurse's station corner had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Corner handrail on the second floor by the stairway had 4 screws sticking out. Additionally, the handrail had gouges and was sharp/rough to the touch In a follow-up wall-through conducted on July 17, 2024 at 8:53 a.m., the following was observed: - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. This included shower doorframe. - Corner handrail by room #2117 was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Corner rail by soiled utility on the second floor had a metal brace that was slightly sticking out. - Second floor nurse's station corner still had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Below the handrail next to linen room on the second floor by room #2133 had a metal brace on the wall corner that is slightly sticking out. That same corner has pieces of the wall corner with severe gouges that is rough/sharp to the touch. - Corner entry to wall to room #2137 had a metal brace that was coming off the wall and the wall corner had severe gouges that was rough/sharp to the touch. - Inside entry wall right hand side in room #2133 has long deep gouges on the lower wall above the baseboard. - Corner handrail on the second floor by the stairway no longer had the 4 screws sticking out. However, the handrail had gouges and was sharp/rough to the touch. An interview with a Registered Nurse (RN/staff #50) was conducted on July 17, 2024 at 8:29 a.m. Staff #50 stated the process for submitting work orders is that they can either use the book, the app, or call the emergency number for maintenance for whoever is on call. When asked about the overall status of the hallways/residents' living area, the RN noted that the place could use a lot of TLC (tender loving care). Staff #50 noted that to their knowledge

Based on observation, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs of 14 residents (#4, #5, #8, #11, #20, #25, #34, #35, #41, #42, #43, #48, #56, and #167). The facility census was 58 and the sample was 13. Findings include: On the morning of July 15, 2024, between the hours of 6:45 a.m. to 7:00 a.m., surveyors experienced a notable difference in temperature perceived and felt when entering the facility. The temperature felt uncomfortably warm. During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at approximately 6:45 a.m., staff #33 mentioned that the generator did not kick in properly during the power outage yesterday evening. This resulted in the cooling tower (chiller) not activating to cool down the temperature in the facility. Staff #33 stated that the chiller is in the process of kicking in but will take approximately 4 hours to cool down the facility. An observation of the residents' areas was conducted on July 15, 2024 starting at approximately 7:15 a.m. There was no evidence that rooms were being tested for ambient temperature by the staff. This was despite the residents' areas being noticeably and feeling warm/uncomfortable. Regarding Resident #4: -Resident #4 was admitted to the facility on June 9, 2024 with diagnoses that included fracture of the lower end of the right femur, pain in right knee, chronic kidney disease, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment dated June 16, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. The assessment also revealed that the resident was dependent for transfers. The MDS indicated that the resident uses a walker as a mobility device. During an interview conducted with the resident on July 15, 2024 at 8:23 a.m., the resident stated that last night they had no power and that she was uncomfortable. An observation was conducted of the resident's room on July 15, 2024 at 8:23 a.m. There was a notable warm temperature in the room. Regarding Resident #5: -Resident #5 was admitted to the facility on June 28, 2023 with diagnoses that included pressure ulcer of sacral region, osteoporosis, hypertension, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated April 5, 2024 revealed that the resident has modified independence pertaining to decisions regarding tasks of daily life. The assessment also indicated that the resident required substantial assistance for chair to bed transfers, and sit to stand activities. The MDS also noted that the resident uses a wheelchair as a mobility device. During an interview conducted on June 15, 2024 at 8:19 a.m., the resident responded "Si" when asked if it was warm in their room. An observation was conducted of the resident's room on June 15, 2024 at

Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff. Findings include: Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage. The following are staff interviews: Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility arriving at 1845 hours. Staff # 32 further stated that the facility was dark and the staff were panicking. Staff # 32 stated that he began troubleshooting and found that the main breaker for the facility had popped and that he reset it. Staff #32 further stated that it took approximately one hour to troubleshoot and that the generator was manually started between 1945 and 2000 hours. Staff # 32 stated that the chillers were not active as they drew too much voltage. Staff # 32 stated that When he arrived at the facility on July 15, 2024, he was unaware that the circular pumps were off. Staff # 32 stated that he later learned that staff #33 had bypassed the circular pumps because he had turned the alarm had been turned off. Staff# 32 stated that had the alarm been on he would have known there was an issue with the circular pumps. Staff #32 stated that at 0700 hours on July 15, 2024, they had to go through the facility and reset all of the AC units. Monday, July 15, 2024, at approximately 1010 hours an interview was conducted with staff # 69, RN unit nurse. Staff # 69 stated that the electricity went out between 1820 and 1830 hours on July 14, 2024. The residents that were on oxygen concentrators had to be switched to O2 tanks due to the electricity being out. Staff #69 stated that the alarm did not go off last night regarding the generator. Staff # 69 further stated that with the electricity being out he knew that the doors needed to be watched to prevent any elopement. Staff # 69 stated that if the resident rooms are hot they should begin moving residents immediately however, if the electricity is out the elevators would not work so they would not be able to move the residents. Staff # 69 stated that he was assuming the generator would kick in right away, but that it did not, and this is why they called maintenance. Monday, July 15, 2024, at approximately 1048 hours, St

Based on record review and staff interview, the facility failed to develop a facility-based emergency planning, training, and testing program. Failure to provide facility-based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients and/or staff during an emergency. Finding include: Based on record review and staff interview on July 17-18, 2024, revealed the facility failed to establish a facility-based training and testing for staff based on the Emergency Plan, and facility risk assessment. During the exit conference conducted on July 18, 2024, the above finding was acknowledged by the management team.

Based on record review and staff interview the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community-based risk assessment poses a potential risk and may cause harm to the patients and/or staff during an emergency. Findings include: Based on record review and staff interview on July 17-18, 2024, revealed the facility failed to provide proof on a community-based risk assessment was used prior to developing the facility's emergency plan During the exit conference on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to ensure the Emergency Preparedness plan included the needs of the patient population they serve and a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population may cause disruption of services to patients during an emergency which could lead to harm. Findings include: Based on record review and staff interview on July 17-18, 2024, revealed the facility failed to develop a plan addressing the needs of the patient population within the current written plan or a delegation of authority as part of the community operations. During the exit conference on July 18, 2024 the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to provide a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on a community and facility-based risk assessment may cause harm to the patients and/or staff during an emergency. Findings include: Based on observation and staff interview on July 17-18, 2024, revealed the facilities policies, were not based on a current risk assessment. CFR 494.62 requires both facility and community hazard assessments but is used to develop the policy and procedures. The assessment provided listed hazards that do not occur in Arizona and the policies don't match the identified hazards. During the exit conference on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to develop and maintain policies to ensure that refrigerated foods were stored at or below 41 degrees. Failure to maintain the appropriate food temperatures could result in bacterial growth resulting in harm to the patients. Finding include Based on observation and staff interview on July 17-18, revealed that problems developed with the refrigerated food storage compartment, and temperatures exceeded 41 degrees for an extended period of time resulting in food having to be thrown out. On July 14, 2024 the facility experienced as power outage and temperatures were documented at 50 degrees fahrenheit. During the exit interview on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to have policies and procedures for safe evacuation from the facility that contains all of the required elements. Failure to provide all of the required elements in the evacuation plan could lead to harm serious injury or death to patients and/or staff. Findings include: Based on record review and staff interview on July 17-18, 2024 revealed, the facility failed to have written policies and procedures regarding the safe evacuation of residents from the second floor in the event of an emergency. On July 14, 2024 the facility experienced a power failure. Because of the total power outage, the facility did not work. Survey team members asked facility staff how they would evacuate the second floor and the staff responded they would wait for the fire department. During the exit interview on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to provide training for new and existing staff which include a review of the facility emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the patients and/or staff during an emergency. Findings include: Based on record review and staff interview on July 17-18, 2024, revealed the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures. In addition, the staff was questioned nobody was able to find the emergency preparedness policies or phone numbers of required numbers. The staff was not familiar the emergency Preparedness program and didn't recall receiving any training. The management was able to find their EP program. During the exit interview on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff. Findings include: Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage. The following are staff interviews: Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility arriving at 1845 hours. Staff # 32 further stated that the facility was dark and the staff were panicking. Staff # 32 stated that he began troubleshooting and found that the main breaker for the facility had popped and that he reset it. Staff #32 further stated that it took approximately one hour to troubleshoot and that the generator was manually started between 1945 and 2000 hours. Staff # 32 stated that the chillers were not active as they drew too much voltage. Staff # 32 stated that When he arrived at the facility on July 15, 2024, he was unaware that the circular pumps were off. Staff # 32 stated that he later learned that staff #33 had bypassed the circular pumps because he had turned the alarm had been turned off. Staff# 32 stated that had the alarm been on he would have known there was an issue with the circular pumps. Staff #32 stated that at 0700 hours on July 15, 2024, they had to go through the facility and reset all of the AC units. Monday, July 15, 2024, at approximately 1010 hours an interview was conducted with staff # 69, RN unit nurse. Staff # 69 stated that the electricity went out between 1820 and 1830 hours on July 14, 2024. The residents that were on oxygen concentrators had to be switched to O2 tanks due to the electricity being out. Staff #69 stated that the alarm did not go off last night regarding the generator. Staff # 69 further stated that with the electricity being out he knew that the doors needed to be watched to prevent any elopement. Staff # 69 stated that if the resident rooms are hot they should begin moving residents immediately however, if the electricity is out the elevators would not work so they would not be able to move the residents. Staff # 69 stated that he was assuming the generator would kick in right away, but that it did not, and this is why they called maintenance. Monday, July 15, 2024, at approximately 1048 hours, St

Based on observation and interview the facility failed to provide a safe means of egress out of the soiled laundry room. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and/or staff in a fire emergency. NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof." Findings include: During a facility tour conducted on July 17-18, 2024, observations made revealed: 1) The entry/exit to the soiled laundry room was blocked by a laundry cart. 2) a medication cart was blocking the fire doors in the 1200 hall. These findings were acknowledged during the exit conference on July 18, 2024, by the management team.

Based on observation the facility failed to ensure proper rated doors were protecting hazardous area. Failing to have proper rated doors and maintain the the self-closing hardware on the door and frame to a hazardous room could cause harm to patients in time of a fire if the door does not close and latch secure. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Chapter 8, 8.7.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: 1. Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 2. Protecting the area with automatic extinguishing systems in accordance with Section 9.7 3. Applying both 8.7.1.1 (1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43. Section 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3/4-hour fire protecting rating and shall be self or automatic closing in accordance with 7.2.1.8. Section 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2. .. Findings include: Observations made while on tour on July 17-18, 2024, revealed the following; 1) Fire door leading to laundry had holes in the upper left portion of the door indicating self closing hardware had been removed. 2) A door was removed from soiled laundry into clean laundry. 3) Laminate chipped on the upper left hinge side of the door entering/exiting the clean laundry room and the door closure was not functioning as the door was propped open. During the exit conference on July 18, 2024,2, the above findings were again acknowledged by the management team.

Based on observation and interview, the facility failed to protect cooking equipment per the requirements of NFPA 101 - 2012 edition, Section 19.3.2.5.3 (9). This deficient practice could affect patients and/or staff causing a fire in the facility. NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... "Chapter 4, Section 4.1.1 "Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard." Section 4.1.2 "All such equipment and its performance shall be maintained in accordance with the requirements of this standard during all periods of operation of the cooking equipment." Chapter 10, Section 10.1.2 "Cooking equipment that produces grease-laden vapors and that might be a source of ignition of grease in the hood, grease removal device, or duct shall be protected by fire extinguishing equipment." Findings include: During a facility tour conducted on July 17-18, 2024, revealed no approved hood system installed in the therapy room of the facility and that the cooking range was plugged in a functioning. During the exit conference on July 18, 2024, the above findings were again acknowledged by the management staff.

Based on observation the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads could result in harm to patients and/or staff in time of a fire. Failure to ensure the plate is present could cause the sprinkler calculation to be inaccurate during a system modification. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7."Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 8, Section 8.5.6 Clearance to Storage. Section 8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4. or 8.5.6.5 are met a clearance between the deflector and the storage shall be 18 inches. (457mm) or greater. NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition - Chapter 5 Sprinkler Systems 5.2.6 * Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. Findings include: Observations made while on tour on July 17-18, 2024, revealed multiple areas within the facility where items were stored within 18 inches of the ceiling. These areas included the following: 1- The maintenance room. 2- The housekeeping room next to the maintenance room. 3- The linen closest outside room 2123 Observations made in the sprinkler riser room revealed the hydraulic plate was missing. During the exit conference on July 18, 2024, the above findings were again acknowledged by the management staff.

Based on observation the facility failed to provide a protective guards on light bulbs located inside building. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage."In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. Findings include: Observations made while on tour on July 17-18, 2024, revealed several light bulbs in the facility were exposed: 1) the records room off the 1100 hall. 2) the housekeeping closet outside room 1226 3) the area behind the clothes dryers in the laundry During the exit conference on July 18, 2024, the above findings were again acknowledged by the management staff.

Based on record review and interview 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 to familiarize staff with conditions under an actual fire can result in harm to patients and/or staff during a an actual fire or emergency situation. NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.7.1.4* "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions." Section 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." Section 19.7.1.7 "When drills are conducted between 9:00 PM and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms." Findings include: Based on record review and interview on July 17-18, 2024 revealed that the facility failed to conduct fire drills during the first shift of the first quarter of 2024 as well as the third shift of the second quarter. During the exit conference on July 18, 2024, the above findings were again acknowledged by the Administrator and Director of Maintenance.

Based on observations and staff interview the facility failed to ensure the generator was permanently mounted. Failing to have the emergency generator permanently mounted could cause harm to patients and/or staff during an emergency. NFPA 110 2010 edition Section 4.4* Level. This standard recognizes two levels of equipment installation, performance, and maintenance. 4.4.2* Level 2 system shall be installed where the failure of the Emergency Power Supply System (EPSS) is less critical to human life and safety. 4.4.3 All equipment shall be permanently installed. NFPA 110 2010 edition Section 7.4 Mounting. 7.4.1 Rotating energy converters shall be installed on solid foundations to prohibit sagging of fuel, exhaust, or lubricating-oil piping and damage to parts resulting in leakage at joints. 7.4.1.1 Such foundations or structural bases shall raise the engine at least 150 mm (6 in.) above the floor or grade level and be of sufficient elevation to facilitate lubricating-oil drainage and ease of maintenance. 7.4.2 Foundations shall be of the size (mass) and type recommended by the energy converter manufacturer. 7.4.3 Where required to prevent transmission of vibration during operation, the foundation shall be isolated from the surrounding floor or other foundations, or both, in accordance with the manufacturer's recommendations and accepted structural engineering practices. 7.4.4 The EPS shall be mounted on a fabricated metal skid base of the type that shall resist damage during shipping and handling. After installation, the base shall maintain alignment of the unit during operation. Finding include: Based on observation and interview on July 17-18, 2024, revealed the facility has had a rental emergency generator for over (4) four years. The facility provided a rental agreement from Power Plus dated March 2, 2020. On July 14, 2024, sometime before 1810 hours, the facility sustained a power outage. The rented portable generator failed to operate as required resulting in a total power loss greater than 30 minutes. Medical equipment such as bilevel positive airway pressure machine (BiPap), oxygen concentrators failed to be utilized for the patients. The facility walk-in refrigerator and walk-in freezer did not have power to them. The facility elevator failed to operate because of no electricity. During the exit conference on July 18, 2024, the above finding was again acknowledged by the management staff.

Based staff interview and record review the facility failed to ensure the emergency generator transferred to emergency power in 10 seconds or under. Failure maintain the facility emergency generator transfer time from normal power to emergency power could result in harm to patients and/or staff during emergency system failures. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 7.9.1 Emergency Lighting. 7.9.1.3 Where maintenance of illumination depends on changing from one energy source to another, delay of not more than 10 seconds shall be permitted. Findings include: Based staff interview and record review on July 17-18, 2024, revealed the facility emergency generator failed to transfer to emergency power in 10 seconds or less during a power outage on July 14, 2024. The entire facility was without power in excess of 30 minutes before the generator as manually started. During the exit conference conducted on July 18, 2024 the above findings were again acknowledged by the management team.

Based on observation and staff interview the facility failed to ensure that appliances are directly plugged into wall outlet receptacles and not power strips. Appliances plugged into power strips could create an overload of the electrical system and could cause a fire which could harm patients and/or staff. NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 "The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code." Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters." Findings include: During a facility tour conducted on July 17-18, 2024, revealed a refrigerator and microwave plugged into a power strip in the maintenance room. During the exit conference on July 18, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility allowed oxygen cylinders to be stored within five feet of combustibles. Allowing oxygen cylinders to be stored near combustible materials could cause harm to the patients and/or staff during a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.3 Cylinder and Container Storage Requirements. 11.3.2 Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1? 2 hour Findings include: Observations made while on tour on July 17-18, 2024, a single unsecured oxygen cylinder being stored next to a rack containing combustible material in a linen closet outside of room 1124. During the exit conference on July 18, 2024, the above findings were again acknowledged by the management staff.