Tempe Post Acute

Based on observation the facility failed to provide a clear means of egress to exit to a public way. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and 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 there from, or visibility thereof. Observations made while on tour on November 25, 2024, the facility failed to maintain a clear path to the exit in the following areas. 1) Hall with rooms 515-522- 4 Hoyer lifts, laundry bin, and briefs cart in means of egress. 2) Hall with rooms 523-532- 4 med carts, Hoyer lift, briefs cart, and laundry bin in means of egress. Management confirmed during the facility tour and the exit conference on November 25, 2025, that the above-listed exit pathways were restricted.

Based on observation the facility failed to ensure that all parts of the facility sprinkler system were properly installed. Failing to ensure proper installation in all areas of the facility could result in the sprinkler not controlling the fire which could cause harm to the residents and staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." 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, 2010 Edition. Chapter 8, 8.6.3.3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. Findings include: Observations made while on tour on November 25, 2024, revealed a ceiling-mounted sprinkler head in the Zone 1 Crash Cart room was 3 \'bc inches away from the wall. The management team acknowledged during the walk-through and exit conference on November 25, 2024, that the ceiling-mounted sprinkler head in the Zone 1 Crash Cart room was to close to the wall.

Based on observation the facility failed to fill multiple penetrations in the smoke barriers of the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke. Findings include: During a facility tour conducted on November 25, 2024, revealed the facility failed to maintain the smoke barriers in the fire/ smoke barrier above the ceiling tiles in the following areas: 1) The water heater room had seven plus areas of penetration (pipes not sealed, patches not sealed) in the walls and ceiling. 2) The westside storage room had penetrations in the ceiling. 3) The east therapy wall has three areas of penetration, a 4"x4" patch not sealed, a 4"x4" hole not sealed, and a 4"x6" patch not sealed. 4) The hallway outside of the therapy room above the 90-minute rated doors had penetrations as did the south wall. 5) The west wall outside room 505 had penetrations. 6) The west wall of room in 505 had penetrations. 7) The mechanical room across from Nursing Station 1 had penetrations above the door. The management team acknowledged the above-listed deficiencies during the facility tour and exit conference on November 25, 2024.

Based on clinical review, staff interviews, and facility policy, the facility failed to ensure that physician orders were followed according to professional standards regarding blood sugar monitoring for two out of five sampled residents (#215 and #46). Findings Include: -Regarding resident #215: Resident #215 was admitted to the facility on November 8, 2024 with diagnoses that included Type II Diabetes Mellitus without complications. The care plan for Diabetes Mellitus initiated on November 09, 2024 included an intervention of diabetes medication as ordered by doctor; monitor/document for side effects and effectiveness. The Minimum Data Set (MDS) assessment dated November 14, 2024 included a brief interview for mental status (BIMS) score of 00 indicating severe cognitive impairment. Review of the physician's order dated November 8, 2024, revealed an order for, Insulin Lispro solution 100 unit/milliliter (ml), inject as per sliding scale: if 0 - 60 =0 units asymptomatic or symptomatic blood sugar (BS) 60 and below; see as needed orders; 61 - 150 = 0 units; 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 12 units; 351 - 400 = 15 units; 401+ = 18 units recheck, if still elevated in 60 minutes call medical doctor (MD), subcutaneously before meals and at bedtime. Review of the Medication Administration Record (MAR) dated November 2024 revealed the following: -November 10, 2024, BS was 447 and 18 units of insulin was administered. -November 12, 2024, BS was 463 and 18 units of insulin was administered. -November 13, 2024, BS was 430 and 18 units of insulin was administered. -November 16, 2024, BS was 491 and 18 units of insulin was administered. -November 17, 2024, BS was 449 and 18 units of insulin was administered. -November 18, 2024, BS was 415 and 18 units of insulin was administered. -November 19, 2024, BS was 402 and 18 units of insulin was administered. -November 20, 2024, BS was 401 and 18 units of insulin was administered. A review of the clinical record revealed no evidence that the BS was rechecked or that the physician was notified for the above dates regarding blood sugar. An interview was conducted on November 21, 2024 at 8:40 AM with a Certified Nursing Assistant (CNA/staff #17) who stated that blood sugar checks are done whenever they are scheduled. She also stated that the blood sugar results are given to the nurses and the nurses document the results in the electronic record. She further stated that she would notify the nurse about blood sugar results in any situation but especially if the resident is below 90 or over 250. In an interview with a Licensed Practical Nurse (LPN/staff #82) on November 21, 2024 at 8:41 AM, who stated that the process for administering insulin included: checking the blood sugar, depending on the result the resident could have either a standard and/or sliding scale order to give insulin, wiping the resident area with an alcohol pad, and administering the medication. She also state