Every finding on record at Arkansas Hospice, Inc

Based on a review of clinical records and staff interviews, it was determined that the agency failed to include all medications utilized by the patient on the medication list for one (#6) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in inadequate medication management, potential drug interactions, and prevent a thorough medication regimen review to ensure patient safety and effective symptom management. Findings follow: --- A review of clinical record #6, with a start of care date of 04/03/25, revealed a patient diagnosed with Amyotrophic Lateral Sclerosis. On a form titled “Visit Note Report" and dated 04/07/25 the Skilled Nurse documented the patient was currently utilizing oxygen. Review of a form titled "Vital Signs Report" revealed the patient "ON OXYGEN" 23 out of 25 visits dated 04/03/25-06/24/25. Review of a form titled "Client Medication Report" did not reflect oxygen as part of the patient’s active medications. There was no documentation in the chart to indicate that oxygen had been checked for actual or potential drug interactions.During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1and #2 confirmed that not all medications had been reviewed for actual or potential drug side effects or interactions. Specifically, oxygen was not listed on the medication profile and had not been assessed for drug interactions.

Based on a review of clinical records and staff interviews, it was determined that the agency failed to include critical Foley catheter management details in the individualized plan of care for one (#19) of five (#1, #10, #11, #16, and #19) clinical records reviewed with catheter orders. Specifically, the plan did not specify the appropriate catheter size nor the replacement frequency. This failure had the potential to impact all patients currently on census with catheter orders and increased the risk of preventable harm (e.g., trauma, infection). Findings follow: --- A review of clinical record #19, with a start of care date of 09/05/24, revealed a patient diagnosed with Malignant Neoplasm of Gallbladder. Review of a form titled “Visit Note Report” and dated 09/10/24 the Skilled Nurse documented “16 FR (French) FOLEY CATH (catheter) INSERTED”. On a document titled “IDG SUMMARY REPORT” and dated 09/12/24 changes to the plan of care since admission include “FOLEY”. Foley catheter orders did not include catheter size, balloon volume, frequency for catheter changes, or clear parameters regarding catheter maintenance. During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1 and #2 confirmed the plan of care did not include specific and individualized foley catheter orders.

Based on a review of clinical records and staff interviews, it was determined that the agency failed to ensure that the Interdisciplinary Group (IDG) updated and coordinated individualized plans of care in response to changes in the condition or needs of the patient in fifteen (#1 - #11, #14, and #17 - #19) of nineteen (#1 - #19) clinical records reviewed. This failure of the IDG to comprehensively assess, coordinate, and revise the plan of care in a timely manner placed all patients currently on census of unmet clinical, emotional, and comfort care needs. Findings follow: --- A review of clinical record #1, with a start of care (SOC) date of 04/28/25, revealed a patient diagnosed with Malignant Neoplasm of Prostate. Review of the Interdisciplinary Group (IDG) Summary dated 05/08/25 revealed the Registered Nurse (RN) left blank the "PROBLEMS IDENTIFIED AT ADMISSION" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION" and the Social Worker left blank "PSYCHOSOCIAL PROBLEMS IDENTIFIED AT EVALUATION VISIT."A review of clinical record #2, with a SOC date of 05/29/25, revealed a patient diagnosed with Senile Degeneration of Brain. Review of the IDG Summary dated 06/05/25 revealed the RN left blank the "PROBLEMS IDENTIFIED AT ADMISSION" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION"A review of clinical record #3, with a SOC date of 06/02/05, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease.  Despite physician orders dated 06/18/25 for new medications (Aspirin and Cetrizine), review of the IDG Summary dated 06/19/25 revealed the RN documented "CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NONE."A review of clinical record #4, with a SOC date of 06/02/25, revealed a patient diagnosed with Congestive Heart Failure.  Despite documented unmanaged pain and physician orders for Lyrica on 06/03/25 review of the IDG Summary dated 06/05/25 revealed the RN left blank the "PROBLEMS IDENTIFIED AT ADMISSION" and documented "CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NONE."A review of clinical record #5, with a SOC of 05/29/25, revealed a patient diagnosed with Malignant Neoplasm of Stomach. Review of the IDG Summary dated 06/05/25 revealed the RN left blank "PROBLEMS IDENTIFIED AT ADMISSION" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION."A review of clinical record #6, with a SOC date of 04/03/25, revealed a patient diagnosed with Amyotrophic Lateral Sclerosis. Review of the IDG Summary dated 04/10/25 revealed the RN left blank "PROBLEMS IDENTIFIED AT ADMISSION" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION" and the Social Worker left blank "PSYCHOSOCIAL PROBLEMS IDENTIFIED AT EVALUATION VISIT."A review of clinical record #7, with a SOC of 06/12/25, revealed a patient diagnosed with Cirrhosis of Liver. Documentation of paracentesis (a medical procedure where a needle or catheter is inserted into the abdominal cavity to drain excess fluid) performed 06/17/25. Review of the IDG Summary dated 06/19/25 revealed the RN documented "PROBLEMS IDENTIFIED AT ADMISSION: NONE" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NO CHANGES TO POC."A review of clinical record #8, with a SOC of 06/04/25, revealed a patient diagnosed with Malignant Neoplasm Unspecified.  Review of the IDG Summary dated 06/05/25 revealed the RN left blank "PROBLEMS IDENTIFIED AT ADMISSION" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION" A review of clinical record #9, with a SOC of 04/08/25, revealed a patient diagnosed with Unspecified Protein-Calorie Malnutrition. Documentation of orders dated 04/09/25 for pain management and wound care. Review of the IDG Summary dated 04/10/25 revealed the RN documented "CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NO CHANGES."A review of clinical record #10, with a SOC of 06/12/25, revealed a patient diagnosed with Senile Degeneration of Brain. Documentation of a fall and multiple skin tears with new wound orders dated 06/13/25. Review of the IDG Summary dated 06/19/25 revealed the RN documented "PROBLEMS IDENTIFIED AT ADMISSION: NONE" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NONE."A review of clinical record #11, with a start of care date of 04/14/25, revealed a patient diagnosed with Nonalcoholic Steatohepatitis (NASH). Review of the IDG Summary dated 04/10/25 revealed the RN left blank the "PROBLEMS IDENTIFIED AT ADMISSION" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION" and the Social Worker left blank "PSYCHOSOCIAL PROBLEMS IDENTIFIED AT EVALUATION VISIT."A review of clinical record #14, with a SOC of 07/02/24, revealed a patient diagnosed with Heart Failure. Documentation of new orders for wound care dated 06/13/25. Review of the IDG Summary dated 06/19/25 revealed the RN documented “CHANGES TO PLAN OF CARE SINCE LAST IDG: NO CHANGES.”A review of clinical record #17, with a SOC date of 06/14/24, revealed a patient diagnosed with Alzheimer’s Disease. Review of the IDG Summary dated 06/20/24 revealed the RN left blank the "PROBLEMS IDENTIFIED AT ADMISSION" and "CHANGES TO THE PLAN OF CARE SINCE ADMISSION."A review of clinical record #18, with a SOC date of 11/18/24, revealed a patient diagnosed with Malignant Neoplasm of Brain. Review of the IDG Summary dated 11/21/24 revealed the RN documented "PROBLEMS IDENTIFIED AT ADMISSION: NONE" and the Social Worker left blank "PSYCHOSOCIAL PROBLEMS IDENTIFIED AT EVALUATION VISIT."A review of clinical record #19, with a SOC date of 09/05/24, revealed a patient diagnosed with Malignant Neoplasm of Gallbladder. Review of IDG Summary dated revealed the RN documented "PROBLEMS IDENTIFIED AT ADMISSION: NONE." All IDG meeting minutes included a directive to "SEE IDG NOTE ADDENDUM FOR ANY CHANGES IDENTIFIED DURING REVIEW." None of the nineteen records reviewed contained and IDG note addendum, indicating a systemic failure to document required care planning updates. During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1 and #2 confirmed the agency failed to document updates to the plan of care in response to new or ongoing clinical needs.

Based on a review of clinical records and staff interviews, it was determined that the agency failed to follow the written plan of care in two (#8 and #11) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in missed or delayed symptom management, ineffective care delivery, and unmet physical, psychosocial, or emotional needs. Findings follow: --- A review of clinical record #8, with a start of care date of 06/04/25, revealed a patient diagnosed with Malignant Neoplasm Unspecified. Review of a document titled “HOSPICE CERTIFICATION AND PLAN OF CARE” with certification dates of 06/01/25 to 09/01/25 revealed orders for a Skilled Nurse (SN) visit two times per week and as needed effective 06/08/25. SN visit documented 06/16/25. One missed SN visit week 06/15/25-06/21/25.A review of clinical record #11, with a start of care date of 04/14/25, revealed a patient diagnosed with Nonalcoholic Steatohepatitis (NASH). Review of a document titled “Order Number: 395005” and dated 04/25/25 revealed orders for a SN visit three times a week. SN visits documented 05/05/25 and 05/09/25. One missed SN visit week 05/04/25-05/10/25.During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1and #2 confirmed the SN missed visits.

Based on a review of clinical records and staff interviews, it was determined that the agency failed to supervise and assess the quality of care and services through on-site Supervisory Aide Visits (SAV) every 14 days in two (#1 and #9) of fifteen (#1, #3, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, and #18) clinical records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family.  Findings follow: --- A review of clinical record #1, with a start of care date of 04/28/25, revealed a patient diagnosed with Malignant Neoplasm of Prostate. Review of a document titled "HOSPICE CERTIFICATION AND PLAN OF CARE" with a certification period of 04/28/2025 to 07/26/2025 revealed orders for a HA. Supervisory aide visits conducted 05/12/25 and 05/27/25 (One day past the required14-day time frame).A review of clinical record #9, with a start of care date of 04/08/25, revealed a patient diagnosed with Unspecified Protein-Calorie Malnutrition. Review of a document titled "HOSPICE CERTIFICATION AND PLAN OF CARE" with a certification period of 04/08/2025 to 07/06/2025 revealed orders for a HA. Supervisory aide visits conducted 05/13/25 and 05/28/25 (One day past the required14-day time frame).During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1and #2 confirmed the Registered Nurse failed to conduct Supervisory Aide Visits every fourteen days as required.

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) did not complete a comprehensive assessment for 3 (#1, #3 and #7) of 5 (#1, #2, #3, #4, and #7) Clinical Records reviewed of patients a documented wound. The absence of a wound assessment had the likelihood to affect all patients needing wound care in that, the RN could not establish the patient's wound care progress. Findings follow: 1. Review of the Agency's Policies and Procedures revealed a Policy number PC.P40 titled, "Plan of Care" with a revised date of 07/01/2022 which read, "The care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the Life Touch Hospice Interdisciplinary Group (IDG) in collaboration with the patient's attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver." 2. Review of Clinical Record #1 showed the following: A. A patient with a start of care (SOC) date of 06/28/22 and a primary diagnosis of breast cancer. B. A form titled, "Team Care Plan" and dated 06/28/22 showed an order, "SN [Skilled Nurse]... Assess wound for location, size, stage, drainage, wound bed, and periwound care..." C. A form titled, "Routine Visit" dated 06/28/22, 07/01/22, 07/06/22, 07/11/22, 07/18/22, 07/25/22 and 07/29/22, showed the Hospice SN documented, "...wound not measured..." D. On 08/05/22 at 09:30 AM, Agency Personnel #1 confirmed the SN did not perform a wound assessment including size, stage, drainage, wound bed, and periwound care as ordered and as part of the comprehensive assessment. 3. Review of Clinical Record #3 showed the following: A. A patient with a SOC date of 05/12/22 and a primary diagnosis of Alzheimer's disease. The patient was a resident of a Skilled Nursing Facility. B. A form titled, "Visit Record" and dated 06/23/22, showed the Hospice SN documented a nursing assessment, "... "Skin is warm; new wound reported per Kizzie, LPN [Licensed Practical Nurse] wound nurse [Skilled Nursing Home's wound care nurse] Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed) noted to coccyx and has infection to right great toe.." There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's coccyx or the right great toe. C. A form titled, "Visit Record" and dated 06/30/22, showed the Hospice SN documented a nursing assessment. There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's coccyx. D. A form titled, "Visit Record" and dated 07/07/22, showed the Hospice SN documented a nursing assessment, "...PU [Pressure Ulcer] to coccyx..." There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's coccyx. E. A form titled, "Visit Record" and dated 07/14/22, showed the Hospice SN documented a nursing assessment, "...wound care nurse [Skilled Nursing Home's wound care nurse] reports that coccyx wound has healed at this time..." There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's coccyx. F. A form titled, "Visit Record" and dated 07/21/22, showed the Hospice SN documented a nursing assessment, "...dressing to left greater toe C/D/I [Clean/Dry/Intact]. There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's left greater toe. G. A form titled, "Visit Record" and dated 07/28/22, showed the Hospice SN documented a nursing assessment. There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's left greater toe . H. On 08/05/22 at 09:30 AM, Agency Personnel #1 confirmed the Hospice SN did not perform wound assessments including size, stage, drainage, wound bed, and periwound care on the patient's coccyx, right great toe and left great toe from 06/23/22 through 07/28/22. 4. Review of Clinical Record #7 showed the following: A. A patient with a SOC date of 08/31/22 and a primary diagnosis of malnutrition. B. A form titled, "Team Care Plan" and dated 08/31/21, showed an order, "SN [Skilled Nurse]... Assess wound for location, size, stage, drainage, wound bed, and periwound care..." C. A form titled, "Visit Record" and dated 08/31/21, showed the Hospice SN documented a nursing assessment, "...pt [patient] has non-healing surgical wound to LLE [Left Lower Extremity] that is dressed by daughter-in-law..." There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's LLE. D. A form titled, "Visit Record and dated 09/09/21, the Hospice SN documented a nursing assessment, "...Non-healing surgical wound to LLE, daughter in law manages wound care..." There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's LLE. E. A form titled, "Visit Record and dated 09/15/21, the Hospice SN documented a nursing assessment, "...Non-healing surgical wound to LLE. Dressing C/D/I [Clean/Dry/Intact]." There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's LLE. F. A form titled, "Visit Record and dated 09/22/21, the Hospice SN documented a nursing assessment, "...Non-healing surgical wound to LLE. LLE erythematosus, swollen, & warm to touch..." There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's LLE. G. A form titled, "Visit Record and dated 09/29/21, the Hospice SN documented a nursing assessment, "..."Non-healing surgical wound to LLE. C/D/I dressing. Pt states she noticed a new wound appear today. Appointment c [with] wound care clinic tomorrow..." There was no evidence the Hospice SN performed an assessment including size, stage, drainage, wound bed, and periwound care of the patient's LLE or "new wound." H. The patient revoked the Hospice benefit on 09/30/21. On a form titled, "Charts/Clinical Notes" and dated 09/30/21 the Hospice SN documented, "Phone call from daughter to notify LTH [Life Touch Hospice] that her mother needs off of hospice d/t [due to] needing wound care and home health." 5. On 08/05/22 at 9:30 AM, Agency Personnel #1 confirmed the Hospice SN did not perform a wound assessment including size, stage, drainage, wound bed, and periwound care from 08/31/21 though 09/30/21 on the above patients. .

Based on Clinical Record review and staff interview, it was determined the Agency did not ensure all orders were complete in 1 (#5) of 2 (#4 and #5) Clinical Records reviewed with urinary catheter orders. The incomplete order had the potential to impact the patient negatively by not providing a change frequency for the urinary catheter and balloon size. The deficient practice could affect all patients on census with orders for a urinary catheters. Findings follow: 1. Review of Clinical Record #5 revealed the following: A. A patient with a diagnosis of end state renal disease and a start of care of 07/08/22. B. A document titled "Team Care Plan," (utilized by the Agency to document the services to be provided to the patient), and dated 07/08/22 contained orders to, " ...Insert catheter & change (specify cath & balloon size, type, and frequency) Foley 18 ..." The order did not contain change frequency and balloon size. C. A document titled, "Visit Record" and dated 07/08/22, showed a patient assessment by the Registered Nurse which included documentation of the patient having an indwelling urinary catheter. 2. On 08/05/2022 at 10:00 AM, Agency Personnel #1 confirmed the lack of a complete order for urinary catheters. .

1. Based on review of Clinical Records, review of Administrative documents for Interdisciplinary Team Meeting Agendas and staff interview, the Agency failed to ensure the Clinical Records were complete and accurate. A. Interdisciplinary Team (IDT) documentation was not incorporated into the Clinical Record at the time of the IDT Meeting in 4 (#2,#3#10 and #11) of 13 (#1 - #13) Clinical Records and IDT Meeting Agendas reviewed. This deficient practice resulted in IDT Meeting information missing in the Clinical Record and had the potential to disrupt the coordination of patient care, which could prohibit Hospice staff from identifying care issues and result in negative patient outcomes. B. The Agency failed to ensure missed patient visits were documented in 3 (#1, #3, #5) of 13 (#1 - #13) Clinical Records reviewed. This deficient practice had the potential to disrupt the coordination of patient care which could prohibit Hospice staff from identifying care issues and result in negative patient outcomes. Findings follow: 1. On 08/02/2022 at 1:00 PM, Agency Personnel #1 reported the Agency documented the plan of care updates in their IDT [Interdisciplinary Team] Meetings in the patient's electronic clinical record. Agency Personnel #1 presented a folder at this time. This folder contained documents titled, "IDT Meeting Agenda" dated the date the IDT occured, IDT members in attendance and the patients discussed. The IDT documentation in the patient's Clinical Records did not match the documentation in the IDT Meeting Agendas as evidenced by the following: A. Review of the form titled, "IDT Meeting Agenda" for Patient #2 showed an IDT Meeting occurred on 07/08/2022. Review of Clinical Record #2 revealed the IDT Meeting occured, 07/12/2022 (4 days later). B. Review of the form titled, "IDT Meeting Agenda" for Patient #3 showed an IDT Meeting occurred on 07/08/2022. Review of Clinical Record #3 revealed the IDT Meeting occured, 07/12/2022 (4 days later). C. Review of the form titled, "IDT Meeting Agenda" for Patient #10 showed an IDT Meeting occurred on 07/22/2022. Review of Clinical Record #10 revealed the IDT Meeting occured 07/26/2022. (4 days later) D. Review of the form "IDT Meeting Agenda" for Patient #11 showed an IDT Meeting occurred on 07/08/2022. Review of Clinical Record #11 revealed the IDT Meeting occured, 07/12/2022 (4 days later). E. On 08/05/2022 at 9:30 AM Agency Personnel #1 confirmed the dates in the patient's clinical records were incorrect for the IDT meetings. 2. Review of Clinical Records (#1, #3, and #5) revealed a form titled, "Team Care Plan" (the document utilized by the Agency to document the services to be provided to patients) which showed the services needed for Aides and Skilled Nurses (SN). Findings follow: A. Review of Clinical Record #1 revealed the "Team Care Plan" contained orders for SN services two times a week. On the week of 07/03/2022 only one SN visit was made. There was no documentation in the patient's clinical record for the missed SN visit. B. Review of Clinical Record #3 revealed the "Team Care Plan" contained orders for Aide services five times a week. On the week of 6/19/2022 only three aide visits were made. On the week of 7/03/2022 only four visits were made. There was no documentation in the patient's Clinical Record for the missed Aide visits. C. Review of Clinical Record #5 revealed orders for Aide services three times a week. On the week of 7/17/2022 only one aide visit was made. On the week of 7/24/2022 no aide visits were made. No documentation of Aide missed visits. 3. On 08/05/2022 at 10:00 AM, Agency Personnel #1 confirmed the lack of a complete and accurate Clinical Record.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 and NFPA 80, it was determined the facility failed to maintain one of four fire-rated door assemblies (Soil Room, Sterile Storage Entrance, Sterile Storage Exit, Chapel Hallway) in accordance with NFPA standards in that one fire-rated door assembly (Soil Room) did not have a self-closing device installed. The failed practice had the likelihood to affect all patients and staff in the building in that the fire-rated door assembly would not close itself in the event of a fire and would allow smoke and fire to transfer through the barrier. Findings follow: A. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. B. Review of NFPA 80 2010 Edition: 5.1.3.2 showed fire-rated doors shall be kept closed and latched or arranged for automatic closing. Review of NFPA 80 2010 Edition: 6.1.4.2.1 showed self-closing doors shall be equipped with a closing device to cause the door to close and latch each time the door is opened. C. Observation on 8/2/22 at 1:10 PM of the Soil Room showed the doorway consisted of a fire-rated door assembly with no closing mechanism installed. This finding was verified with the Director of Maintenance at the time of observation. .

Based on observation, interview, and review of NFPA 101 2012 Edition, it was determined the facility failed to maintain one of three (Soil Room, Sterile Storage, Chapel Hallway) smoke barriers in accordance with the requirements of NFPA 101 2012 Edition in that one barrier (Chapel Hallway) had penetrations which were not sealed with a firestop system or device to restrict the transfer of smoke. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors, and staff in the facility in the event of a fire. Findings follow: A. Review of NFPA 101 2012 edition, 8.4.4.1, showed where penetrations for conduits that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier shall be protected by a system or material capable of restricting the transfer of smoke. B. Observation on 8/3/22 at 10:15 AM of the smoke barrier separating the Chapel Hallway from the Inpatient Unit showed two metal rods, three blue cables, and one conduit penetrating the barrier were not sealed to restrict the transfer of smoke, resulting in four holes each approximately 4 inches in diameter in the barrier. This finding was verified with the Director of Maintenance at the time of observation. .

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 and NFPA 80, it was determined the facility failed to maintain four of four fire-rated door assemblies (Soil Room, Sterile Storage Entrance, Sterile Storage Exit, Chapel Hallway) in accordance with NFPA standards in that no annual inspection was being conducted of the fire-rated door assemblies in the facility. Findings follow: A. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 5.2.1 showed fire door assemblies shall be inspected and tested not less than annually. B. In an interview on 8/2/2022 at 3:00 PM with the Director of Maintenance it was verified the facility did not conduct any annual inspection or testing of the fire-rated door assemblies in the building. .

Based on interview and review of the facility's generator logs and National Fire Protection Association (NFPA) 101 and NFPA 110, it was determined the facility failed to maintain one of one emergency generator as required by NFPA 101 Life Safety Code 2012 Edition in that the emergency generator was not being tested under load monthly and failed to ensure functionality in the event of an emergency. The failed practice had the likelihood to affect all patients, staff, and visitors in that in the event of a power outage emergency the generator may not function properly and could fail to support all equipment and emergency lighting relying on the essential electrical system for emergency power. Findings follow: A. Review of NFPA 101 2012 Edition: 9.1.3 showed emergency generators must be installed and maintained in accordance with NFPA 110 Standard for Emergency and Standby Power Systems. B. Review of NFPA 110 2010 Edition: 8.4.1 showed EPS (emergency power supply) systems shall be inspected weekly and exercised under load at least monthly. Further review of NFPA 110 2010 Edition: 8.4.2 showed diesel generator sets shall be exercised monthly under load for 30 minutes using either loading that maintains the minimum exhaust temperatures recommended by the manufacturer under operating temperature and not less than 30 percent of the EPS nameplate kW (kilowatt) rating. Further review of NFPA 110 2010 Edition: 8.4.2.3 showed diesel-powered EPS systems that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. C. In an interview on 8/2/2022 at 3:00 PM with the Director of Maintenance it was verified there was no documentation of the emergency generator being run under load for 30 minutes monthly or exercised annually in the 12 months prior to the survey (August 2021 through July 2022).