Every finding on record at Lifecare Hospice

Based on record review and interview the facility failed to ensure the was a fire alarm system was maintained in accordance with the LSC, 2012 Edition 9.6.1, 9.6.2 and 9.6.3. This deficient practice had the potential to affect all three patients who reside within the facility. Findings include: During the record review with the Facility Manager (FM) on 03/03/25 at 1:30 P.M. it was revealed that the fire alarm system was not being maintained as required. The documentation provided did not show a semi-annual visual inspection had been completed. No additional documentation was provided at the time of survey to validate the inspection was complete. Interview with the FM verified the finding at the time of the review.

Based on observation and staff interview, the facility failed to ensure the installation of sprinkler system throughout the facility in accordance with NFPA 101 - 2012 Edition, Section 19.3.5.1, NFPA 99 – 2012 Edition 15.8, and NFPA 13 – 2010 Edition Section 8.1. This deficient practice had the potential to affect all three patients who reside within the facility. Findings include: Observation on 03/03/25 during tour of the facility at 10:30 A.M. identified the lack of sprinkler protection installed in the walk-in cooler in the kitchen. Interview with the Facility Manager verified the finding at the time of observation.

Based on review of facility fire drill documentation and staff interview, the facility failed to conduct quarterly fire drills in accordance with NFPA 101-2012 Edition, Section 19.7.1. This deficient practice had the potential to affect all three patients who reside within the facility. Findings include: On 03/03/25 at 2:20 P.M. review of last twelve months of the fire drill documentation with the Facility Manager (FM) indicated drills were not completed as required. Further review noted the documentation did not include fire drills for the months of December 2024 or January 2025. No additional documentation was provided at the time of survey to validate the drills were complete in accordance to the applicable code. Interview with the FM verified the finding at the time of the review.

Based on record review and interview the facility failed to ensure the emergency generator is exercised monthly under load for 30 minutes in accordance with the LSC, 2012 Edition 8.3.1 through 8.3.4 and 8.4.1 through 8.4.2.3. This deficient practice had the potential to affect all three patients who reside within the facility. Findings include: At 2:30 P.M. during the generator record review with the Facility Manager (FM) on 03/03/25 it was revealed that the diesel generator monthly operational testing was not completed in accordance with the applicable code. The generator documentation provided lacked the required elements of the weekly inspection. The monthly run test of the generator indicated the load did not calculate and verify that the load achieved at least 30% of the rating. No additional documentation was provided at the time of survey to validate the inspections were complete. Interview with the FM verified the finding at the time of review.

Based on record review, observation and interview; the facility failed to ensure life safety from fire. --- See L827

Based on record review, observation and interview; the facility failed to ensure life safety from fire. --- See Life Safety Code Survey Report.

Observed in Record Review. In 14 of 16 patient records reviewed, there were no individualized measurable outcomes or time frames included in the plans of care that would identified when planned goals had been met. This was discussed with the Dir. of Compliance and the clinical managers.

Observed in Data Tracer. In review of the governing body meeting minutes and the QAPI meeting minutes for the previous 2-3 years, there was no discussion documented in these meeting minutes that the board had addressed performance activities and patient outcomes. Nor was there documentation that the board had reprioritized performance activities based on changes in the community and then identified the frequency of data collection to make sure that the priorities were directed towards improvements in patient safety and quality of care as required by regulation. This was discussed with the Dir. of Compliance.

Observed in Patient Home. In 2 of 4 home visits conducted, during home visits #2 and #3, it was observed that the nurses failed to follow agency policy by not keeping their clinical bags closed during the visit. This was also observed by and discussed with the clinical managers.

Observed in Record Review. In 2 of 4 home visits conducted, the agency MARS (medication administration record) did not match the medications found in the home. For example at home visit #1, the following medications were found on the facility's MAR but not on the agency's MAR: Chamosyn topical cream; the 3rd dose of morphine; artificial tears eye drops. These medications were on the agency MAR but not the facility MAR: Acetaminophen 325mg 2 tabs PO PRN; Bisacodyl suppository; and Senna Plus. At home visit #2 the wife had not picked up the Oxycodone or Ativan medications from the pharmacy because she didn't believe that he needed them; no Mirtazapine in the home; the patient's PCP changed the Klor-Can M20meq order from 1 tab PO three times daily to 1 tab 2 times daily about 2 months ago. These changes were not corrected on the agency's MAR. This was discussed with the clinical managers.

Observed in Document Review. In 4 of 6 contracts reviewed, there were no expectations included in the contracts stating how the organization would be evaluating the contractor (DME, Transportation, Pharmacy, Rehab).. This was discussed with the Dir. of Compliance. Observed in Document Review. In discussion with the DON regarding the evaluation of contractors, she stated that the organization has not conducted any contract evaluations.

Observed in Building Tour. In 5 of 5 above ceiling checks, there were multiple unsealed penetrations in the ceilings above the fire doors in the IPU . For example at the entrance to the unit, 2 of 4 pipes demonstrated holes in the caulking mud. Inside the entrance to the unit the EZ path was sealed with a clear silicone and not fire retardant caulking. There was no caulking on 3 pipes above the fire doors by the family laundry room. The pipes above the fire door by room 3 were demonstrating holes in the caulking. There was no caulking around the pipes in the electrical room . This was discussed with the Dir. of Compliance. Corrected on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. During the building tour, it was observed that several fire extinguishers did not meet the requirements of visibility and distance. For example, the fire extinguisher in the north hallway by the exit door was greater than 75 feet from the next extinguisher that was located in the nursing station. There was a fire extinguisher within 75 feet but it was inside a mechanical room which was locked. The fire extinguishers in the great room and the nursing station were not easily visible from the hallway nor was the extinguisher at the end of the south hallway. This was discussed with the Dir. of Compliance. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Building Tour. The facility manager stated that he had not been testing the water temperature n the patient rooms as required by regulation. This was validated by the Dir. of Compliance.