Every finding on record at Olathe Medical Center, Inc.

Observed in Record Review. In 3 out of 17 active patient records reviewed, the organization failed to complete a bereavement assessment on admission. On RRIPHV #3 it was noted that a bereavement risk assessment was not completed because the social worker did not make a visit. On RRNHV #7 and RRNHV #9, it was noted that the social worker was refused and so there was no bereavement risk assessment completed on admission. This observation was discussed with the Hospice director.

Observed in Record Review. In 12 of 17 active patient records reviewed, the organization failed to plan the patient’s care with measurable and time specific goals. On RRHV #2, goals not measurable and specific with the examples of “Patient/family will express satisfactory control of symptoms” and “Patient /Caregiver will demonstrate adequate coping skills”. On RRNHV #2, goals not measurable and time specific with an example of “Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters” and “Patient will maintain a pain score of ___ or less, per patient/family preference, on a scale of 0-10”. On RRIPHV #1, RRIPHV #2, RRIPHV #3, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #8 and RRNHV #10 goals were not measurable and specific with examples of: “Patient passes soft, formed stool at a frequency that is normal for the patient”, “Patient /Caregiver will demonstrate adequate coping skills regarding loss”, “Patient will have optimal nutritional status”. “Patient passes soft, formed stool at a frequency that is normal for the patient”. “Patient will be pain free or verbalize an acceptable pain level with current pain management regimen”, Pt will maintain optimal bowel functioning”, “Reduce the risk of skin breakdown”., Establish/maintain normal bowel habits”, “demonstrate adequate coping skills regarding loss”. This observation was discussed with the Hospice director.

Observed in Record Review. In 4 of 17 active charts reviewed, the organization did not have treatments necessary to meet patient's needs on the plan of care. On RRHV #1, it was noted during the home visit that the bilateral nephrostomies were being cleaned and dressed differently due to drainage on the left side but the orders did not specify the specifics of the care for the nephrostomy, it just said change dressing weekly and PRN. On RRIPHV #1 and RRIPHV #3, it was noted that the Chaplain had performed a visit with the patient but there were no orders for the visit. On RRIPHV #2, it was noted that the MSW and Chaplain had both performed visits with the patient but there were no orders on the plan of care for either discipline. This finding was reviewed with Hospice director.

Observed in Record Review. In 2 out of 17 active patient records reviewed, the organization failed to plan the patient's care. On RRHV #1, it was noted that patient was getting weekly dressing changes to nephrostomy tubes with one side having yellow drainage but there were no goals developed around this issue. On review of RRNHV #3, it was noted on assessment and CTI that patient has sleep disturbances that are affect comfort but there is not goals or interventions around sleep on the plan of care. This observation was discussed with the Hospice director.

Observed in Record Review. In 1 of 17 patient records reviewed, the organization did not have all medications on the plan of care to meet patient’s needs. On RRNHV #5, patient had a PICC line and the nurse is flushing the line during home visits but there is no detail on the plan of care of the type and amount of flush used. This observation was discussed with the Hospice director.

Observed in Record Review. On 7 of 17 active patient records reviewed, the organization did not updated the plan of care and address progress toward goals. On RRHV #1, it was noted goals not updated to reflect current needs of patient or progress towards the goals with teaching goals still present from admission 4 months ago with example of Teach/reinforce medication dosages, administration, actions/side effects, possible interactions, s/s to report to RN/MD” and “Patient /caregiver will verbalize understanding of falls/injury prevention and home safety measures”. On RRHV #2, it was noted that patient’s plan of care has not been updated to reflect goals that have been achieved, for example patient has been on service for 7 months and is independent with his catheter care but there is still teaching goals for care and understanding of the catheter. On RRHV #3, it was noted that patient is a skilled facility but plan of care still had outdated information from before move to the skilled facility. On RRHV #4, goals and progress toward goals not updated to reflect changes in care, for example patient had a wound 4 months ago that is healed but there are still goals and interventions for that issue on the Plan of Care. On RRNHV #2, it was noted that patient has been on service for 4 months and the teaching goals from admission are still on the plan of care with no update on the progress. With the example of “Patient/caregiver verbalize understanding/demonstrate proper handwashing”. On RRNHV #7, patient has been on service for 3 months and goals have not been updated with admission teaching goals still present. On RRNHV #10, the patient is in 4th benefit period and still has admission teaching goals on POC with no update on progress or achievement of the goal. This observation was discussed with the Hospice director.

Observed in Data Session. On review of the Hospice QAPI program, the organization had not integrated their infection control program into their overall QAPI plan that included the surveillance of infections. This finding was reviewed with the Hospice Leadership team.

Observed in Record Review. In 2 of 3 bereavement plans of care, there was no individualized bereavement plan based on assessed risk. On RRBR #2 and RRBR #3, the plan of care did not reflect the services per the agency policy. Agency policy is that a sympathy card would be mailed out within 30 days of death but there is not tracking that card was sent. In addition, the policy did not delineate specific frequency of additional mailings just that they would be sent and the plans of care did on specify the frequency of the mailings either. This observation was discussed with the Hospice director.

Observed in HR File Review. On 1 of 8 HR files reviewed, the organization did not have initial competency assessed on hire. On HR #6, it was noted that the chaplain did not have an initial competency assessment completed on hire. This finding was reviewed with the Hospice Administrator.

Observed in Record Review. On 3 of 3 active patient records reviewed in the inpatient unit, the medical director had not completed the CTI in 2 days of admission or had a verbal certification completed. On RRIPHV #1, RRIPHV #2 and RRIPHV #3, it was noted that the patients have been on service for greater than 2 days and the CTI had not been completed. Their was a verbal order to the physician on each that the patient had a terminal dx but there was no subjective medical findings, and information about medical conditions of the patient in that verbal. This finding was reviewed and discussed with the Hospice Director.

Observed in Record Review. On 2 of 4 home visits conducted, the organization did not have an accurate medication list in the patient's home. Agency policy states that the patient medication list will be updated when changes to medication occur. On RRHV #1, it was noted that the patient had a handwritten medication list from admission from the agency and there have been changes to dosage for furosemide and Carvedilol that had not been updated on the home medication list. On RRHV #4, it was noted during the home visit that the patient did not have a medication list in the home, and the patient has been on service for over 6 months. On discussion with the daughter who is a caregiver, she had not received a medication list from the hospice until my visit when the nurse brought it at the visit. This finding was reviewed with Hospice supervisor who was on the visit.

Observed in Building Tour. In the water heater mechanical room (area protected with a fire sprinkler system) a ceiling tile was missing. This was verified by the facilities team and the hospice leadership team. 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. An extension cord with a molded three connection was being used to provide electrical power for two individual vending machines on the enclosed porch. This was verified by the facilities team.

Based on observation, policy review, record review, and interview, the Hospice failed to include in the plan of care (POC) a volunteer intervention and goal for 3 (Patient 5, 6, and 9) of 22 sampled patients. Failure to ensure the POC includes all interventions and goals necessary services for management of patient needs places the patients at risk for unmet care needs. --- Findings Include: Review of the Hospice policy titled “Documentation Standards Home Care & Hospice” last revised 11/01/23 showed “Each clinical record contains at least the following: … Drug, dietary, treatment, and activity physician orders …” Review of the Hospice policy titled “Home Health Initial Plan of Care and Recertification” last revised 08/01/22 showed “Upon admission to home health service, a comprehensive assessment is completed to include the patient’s needs based on condition, need and desire for care or service …” Review of the Hospice policy titled “Hospice Interdisciplinary Team” last revised 08/01/2022 showed “The Interdisciplinary Team is responsible for: … Establishment of the individual patient plans of care … Periodic review and updating of the plan of care for each patient receiving hospice care … The registered nurse will be responsible for maintaining the team plan of care in the patient record.” Patient 5 Review of Patient 5’s record showed a 72-year-old home patient admitted hospice services on 12/06/24 with a primary diagnosis of chronic obstructive pulmonary disease (damage to the lungs causing inflammation and decrease in air flow). Review of Patient 6’s POC dated 12/06/24 listed volunteer services 1 to 4 times monthly starting on 12/16/24.  Further review of Patient 6’s POC dated 12/06/24 did not show an intervention or goal for volunteer services.  Patient 6 Review of Patient 6’s record showed a 62-year-old assisted living resident admitted to hospice services on 10/11/24 with a primary diagnosis of striatonigral degeneration (neurological disorder caused by a disruption in the connection between two areas of the brain).  Review of Patient 6’s face sheet showed volunteer visits 1 to 2 times monthly starting 04/06/25.  Review of Patient 6’s interdisciplinary group (IDG) meeting notes on 01/22/25 showed volunteer visits 1 to 2 times monthly starting 01/16/25.  Review of Patient 6’s POC dated 12/24/24 through 03/23/25 failed to show an intervention or goal for volunteer services.  Review of Patient 6’s POC dated 03/24/25 through 05/22/25 failed to show an intervention or goal for volunteer services.   Patient 9 Review of Patient 9’s record showed a 79-year-old home patient admitted on 01/04/25 with a primary diagnosis of malignant neoplasm of the right lung or bronchus (lung cancer).  Further review of Patient 9’s record showed volunteer visits performed on 03/07/25 and 03/12/25. Review of Patient 9’s POC dated 01/04/25 failed to show an intervention or goal for volunteer services.  Review of Patient 9’s POC dated 04/04/25 failed to show an intervention or goal for volunteer services.  During an interview on 04/30/25 at 9:30 AM, Staff A, Administrator stated that any patients receiving volunteer visits should have listed on their individual POC an intervention and goal for volunteer services.

Based on policy review, record review, and interview, the Hospice failed to include in the plan of care (POC) the frequency of services for 2 patients (Patient 9 and 21) of 22 sampled patients. Failure to include the frequency of services in the POC places the patient at risk for unmet care needs. --- Findings Include: Review of the Hospice policy titled “Documentation Standards Home Care & Hospice” last revised 11/01/23 showed “Each clinical record contains at least the following: … Drug, dietary, treatment, and activity physician orders …” Review of the Hospice policy titled “Home Health Initial Plan of Care and Recertification” last revised 08/01/22 showed “Upon admission to home health service, a comprehensive assessment is completed to include the patient’s needs based on condition, need and desire for care or service …” Review of the Hospice policy titled “Hospice Interdisciplinary Team” last revised 08/01/2022 showed “The Interdisciplinary Team is responsible for: … Establishment of the individual patient plans of care … Periodic review and updating of the plan of care for each patient receiving hospice care … The registered nurse will be responsible for maintaining the team plan of care in the patient record.” Patient 9 Review of Patient 9’s record showed a 79-year-old home patient admitted on 01/04/25 with a primary diagnosis of malignant neoplasm of the right lung or bronchus (lung cancer).  Further review of Patient 9’s record showed volunteer visits performed on 03/07/25 and 03/12/25. Review of Patient 9’s record showed a volunteer coordinator phone call on 03/13/25 at 3:15 PM in which Patient 9’s spouse stated wanting to continue to use a volunteer for visits.  Review of Patient 9’s POC dated 01/04/25 did not list volunteer frequency of visits.  Review of Patient 9’s POC dated 04/04/25 did not list volunteer frequency of visits.   Patient 21 Review of Patient 21’s record showed a 90-year-old assisted living (AL) resident admitted to hospice services on 04/03/24 with a primary diagnosis of malignant neoplasm of the pancreas (pancreatic cancer) and discharged due to death on 10/23/24. Review of Patient 21’s record showed no home health aide (HHA) visits performed from 07/06/24 through 08/13/24 then being performed 2 times weekly starting on 08/14/24 through 09/29/24.  Review of Patient 21’s record showed a communication note on 07/05/24 from the registered nurse (RN) stating that Patient 21’s daughter wanted to discontinue HHA visits.  Review of Patient 21’s POC dated 07/02/24 through 09/29/24 showed an HHA frequency of 2 times weekly discontinuing on 07/09/24 but no new frequency started on 08/14/24.  During an interview on 04/30/25 at 9:30 AM, Staff A, Administrator, stated that during interdisciplinary group (IDG) all discipline frequencies are reviewed and updated at that time by the registered nurse (RN) case manager. Staff A, Administrator, stated that all disciplines performing visits should have a visit frequency listed.

Based on observation, policy review, record review, and interview, the Hospice failed to include in the plan of care (POC) a complete list of durable medical equipment (DME) for 4 patients (Patient’s 5, 6, 7, and 13) of 22 sampled patients. Failure to include the DME required to manage the care needs of the patient, places the patients at risk for unmet care needs. --- Findings Include: Review of the Hospice policy titled “Documentation Standards Home Care & Hospice” last revised 11/01/23 showed “Each clinical record contains at least the following: … Drug, dietary, treatment, and activity physician orders …” Review of the Hospice policy titled “Hospice Interdisciplinary Team” last revised 08/01/2022 showed “The Interdisciplinary Team is responsible for: … Establishment of the individual patient plans of care … Periodic review and updating of the plan of care for each patient receiving hospice care … The registered nurse will be responsible for maintaining the team plan of care in the patient record.”  Patient 5 Review of Patient 5’s record showed a 72-year-old home patient admitted hospice services on 12/06/24 with a primary diagnosis of chronic obstructive pulmonary disease (damage to the lungs causing inflammation and decrease in air flow).  Review of Patient 5’s POC and DME list dated 12/06/24 showed a wheelchair.  Review of Patient 5’s current POC and DME list dated 03/06/25 did not list a wheelchair. Patient 6 Review of Patient 6’s record showed a 62-year-old assisted living resident admitted to hospice services on 10/11/24 with a primary diagnosis of striatonigral degeneration (neurological disorder caused by a disruption in the connection between two areas of the brain). Review of Patient 6’s POC and DME list dated 12/24/24 listed the following equipment: wheelchair, and shower chair.  Review of Patient 6’s current POC and DME list dated 03/24/25 failed to list a shower chair.   Patient 7 Review of Patient 7’s record showed a 61-year-old home patient admitted to hospice services on 03/11/24 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (ineffective pump of the heart). Review of Patient 7’s initial POC and DME list dated 03/11/24 listed the following equipment: cane, wheelchair, and walker.  Review of Patient 7’s current POC and DME list, dated 03/06/25 failed to list the following equipment: cane, wheelchair, and walker.  Patient 13 Review of Patient 13’s record showed a 96-year-old home patient admitted to hospice services on 08/08/24 with a primary diagnosis of hypertensive (high blood pressure) heart disease and chronic kidney disease with heart failure (ineffective pump of the heart).  Observation during a home visit for Patient 13 on 04/24/25 at 10:30 AM, showed the following equipment present in Patient 13’s apartment: electric wheelchair, wheelchair, and rollator walker.  Review of Patient 13’s current POC and DME list, dated 02/04/25, failed to list the following equipment: electric wheelchair, standard wheelchair, and rollator walker.  During an interview on 04/30/25 at 9:30 AM, Staff A, Administrator, stated that all DME that the patients require should be listed on the current POC and any changes to the DME should be updated during interdisciplinary group (IDG) meetings at least every 2 weeks.

Based on policy review, record review, and interview, the Hospice failed to communicate medication changes with non-hospice caregivers for 1 patient (Patient 3) of 22 patients sampled. Failure to provide an accurate medication list with non-hospice caregivers places these patients at risk for unmanaged symptoms and negative outcomes. --- Findings Include: Review of the Hospice policy titled “Home Health and Home Hospice Medication Administration and Documentation” last revised 09/01/2022 showed “A medication profile, completed for each patient at time of admission, will be updated as indicated by patient need and regulation. … It is the responsibility of the case manager to assure the medications are updated on the electronic medication list and on the medication list in the home.” Review of the Hospice policy titled “Hospice Interdisciplinary Team” last revised 08/01/2022 showed “The registered nurse will be responsible for maintaining the team plan of care in the patient record. … The registered nurse is responsible for communication of the team plan of care to the patient’s primary care giver, and other significant care givers.   Patient 3 Review of Patient 3’s record showed an 87-year-old skilled nursing facility (SNF) resident admitted to hospice services on 09/05/24 with a diagnosis of senile degeneration of the brain (a state of mental, emotional, and social deterioration of brain). Review of Patient 3’s medications showed the following: 1. Review of Patient 3’s plan of care (POC) medication list and “Medication Profile” dated 04/24/25, showed Lorazepam 2 mg/mL concentrate, 0.25 mL by mouth, every 4 hours PRN for anxiety. Review of Patient 3’s residing facility’s medication record dated 04/24/25 failed to list Lorazepam. 2. Review of Patient 3’s plan of care (POC) medication list and “Medication Profile” dated 04/24/25, showed MiraLax powder, 17 gm(s) by mouth once a day as PRN for constipation. Review of Patient 3’s residing facility’s medication record dated 04/24/25 failed to list MiraLax. 3. Review of Patient 3’s plan of care (POC) medication list and “Medication Profile” dated 04/24/25, showed Nystatin 100,000 units/gm, apply 1 inch topical 3 times a day for yeast to groin. Review of Patient 3’s residing facility’s medication record dated 04/24/25 failed to list Nystatin. 4. Review of Patient 3’s plan of care (POC) medication list and “Medication Profile” dated 04/24/25, showed Alprazolam 0.5 mg, 1 tab by mouth every morning and 3 times a day PRN for restlessness. Review of Patient 3’s residing facility’s medication record dated 04/24/25 failed to list Alprazolam.

Based on record review, policy review, and interview, the Hospice failed to ensure a supervisory visit was performed for the home health aide (HHA) at least every 14 days by a registered nurse (RN) for 2 (Patient 2 and 10) of 22 patients sampled. Failure to ensure an RN supervisory visit for the HHA is made at least every 14 days places these patients at risk for unmet care needs. --- Findings Include:  Review of the Hospice policy titled “Documentation Standards Home Care & Hospice” last revised 11/01/23 showed “Each clinical record contains at least the following: … Date of each on-site visit for supervision …” Review of the Hospice policy titled “Scope of Services – Home Health” last revised 05/01/23 showed “Home Health Aide services are provided under the supervision of a registered nurse … A physician, RN, or appropriate qualified health professional shall visit each patient’s home every two weeks to supervise the HH services …”. Review of the Hospice policy titled “Hospice Interdisciplinary Team” last revised 08/01/2022 showed “The Interdisciplinary Team is responsible for: … Establishment of the individual patient plans of care … Provision or supervision of hospice care and services”. Patient 2 Review of Patient 2’s record showed an 89-year-old home patient admitted to hospice services on 01/08/25 with a primary diagnosis of Alzheimer’s disease with late onset (a brain condition that slowly damages your memory, thinking, learning and organizing skills).  Further review of Patient 2’s record showed an initial RN supervisory visit performed on 01/22/25 and a subsequent RN supervisory visit performed on 02/17/25, with a total of 26 days between RN supervisory visits.   Patient 10 Review of Patient 10’s record showed an 85-year-old home patient admitted to hospice services on 02/06/25 with a primary diagnosis of specified disease of the spinal cord. Further review of Patient 10’s record showed an RN supervisory visit performed on 02/21/25 and a subsequent RN supervisory visit performed on 03/14/25, with a total of 21 days between RN supervisory visits. During an interview on 04/30/25 at 9:30 AM, Staff A, Administrator, stated that an RN supervisory visit should be made at least every 14 days and upon review of Patient 2’s and Patient 10’s records found a period of greater than 14 days between RN supervisory visits.

Based on observation and interview the Hospice failed to provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoid sources and transmission of infections and communicable diseases. This deficient practice places immune compromised patients at greater risk of contracting disease or infection leading to a diminished quality of life. --- Findings Include:  Review of the Hospice policy titled “Equipment and Responsibility” last revised 08/01/19 showed “All departmental mechanical/electrical equipment will be serviced by the … Biomedical Engineering Department. … Routine safety checks and preventative maintenance are the responsibility of Biomedical Engineering Department and will be performed annually …” Review of the Hospice policy titled “Infection Control Program and Practices in Home Care” last revised 08/01/19 showed “Infection prevention and goals may include, but not be limited to, the following: … Preventing the spread of infection associated with the use of medical equipment, devices and supplies …” During a tour of the Hospice inpatient house on 04/28/25 at 1:30 PM, the observation showed 4 reclining chairs in patient rooms had significant wear and ripping of the material covering the seat and arms of the chairs. During an interview on 04/28/25 at 2:50 PM, Staff G, Nursing Supervisor, stated that any damaged furniture or equipment is tagged and reported to the hospice administrator for repair or replacement. Staff G, Nursing supervisor, stated that the hospital maintenance and medical equipment team would perform the repairs or replacement of equipment if authorized.  During an interview on 04/30/25 at 9:30 AM, Staff A, Administrator, stated that the damaged reclining chairs had been tagged and pulled from service by the maintenance team for repair or replacement.

Based on review of the Emergency Preparedness Plan (EPP) and interview, the Hospice failed to have a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials as part of its emergency plan. This deficient practice has the potential to place patients at risk for unmet needs during an emergency. --- Review of the agency's Emergency Preparedness Program (EPP), last reviewed by the facility in February 2025, failed to include policies or procedures for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials as required by §418.113(a)(4).During an interview on 04/25/25 between 8:30 AM and 11:30 AM, the Emergency Preparedness Coordinator confirmed that there were no policies or procedures for the required collaboration with local, state, tribal, and federal emergency preparedness officials.

Based on review of the Emergency Preparedness Plan (EPP) and interview, the Hospice failed to have policies or procedures addressing the provision of food, water, medical and pharmaceutical supplies, or alternate sources of energy for maintaining essential services such as safe temperatures, emergency lighting, fire protection systems, and waste disposal. This deficient practice has the potential to place patients at risk for unmet needs during an emergency. --- Review of the agency's Emergency Preparedness Program (EPP), last reviewed by the facility in February 2025, failed to include policies or procedures for the provision of subsistence needs for hospice employees and patients as required by §418.113(b)(6)(iii).During an interview on 04/25/25 between 8:30 AM and 11:30 AM, the Emergency Preparedness Coordinator confirmed there were no policies or procedures in place for providing subsistence needs or ensuring essential services through alternate energy sources in the event of an emergency.

Based on review of Emergency Preparedness Plan (EPP) and interview, the Hospice failed to develop and maintain a communication plan that includes methods for sharing patient information and medical documentation with other healthcare providers to ensure continuity of care during an emergency and did not include a means of providing information about the general condition and location of patients during an evacuation. This deficient practice has the potential to disrupt the continuity of care for patients during an emergency. --- Review of the agency's Emergency Preparedness Program (EPP), last reviewed by the facility on February 2025, failed to include policies or procedures for:Sharing patient information and medical documentation to maintain continuity of care with other healthcare providers, providing a means to release patient information during an evacuation, as permitted under 45 CFR 164.510(b)(1)(ii), providing information about the general condition and location of patients under the facility’s care, as permitted under 45 CFR 164.510(b)(4).During an interview on 04/25/25 between 8:30 AM and 11:30 AM, the Emergency Preparedness Coordinator confirmed there were no documented policies or procedures for the methods of sharing patient information, including during an evacuation, nor was there any plan for disseminating information about the location or condition of patients.

Based on observation and interview, the facility failed to comply with NFPA 101, 2012 edition, Section 19.1.6.7, which requires all interior stud partitions to be fire stopped to prevent the passage of fire and smoke. Specifically, unprotected wall cavities observed following HVAC modifications create vertical draft openings, compromising fire containment. This deficient practice affects all patients, staff, and visitors in 1 of 3 total smoke zones. --- Findings Include:On 04/25/25 it was observed:At 10:57 AM in the Main Breaker Room, a large section of drywall was missing following completion of HVAC remodeling work. This exposed the interior wall cavity and ceiling space, allowing for the free passage of fire and smoke between floors and into the smoke compartment, violating required firestopping provisions.The Life Safety Specialist was present and acknowledged the deficiency.Reference: NFPA 101, 2012 edition, Chapter 19.1.6.7Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor, and such firestopping shall consist of wood not less than 2 in. (51 mm) thick or shall be of noncombustible material.

Based on observation, the facility failed to provide egress doors that will open as designed and without extra force. This deficient practice could delay the expedient egress of residents, visitors, and staff in 1 of 3 smoke zones. The facility has a capacity of 8 and census of 6 at the time of the review. Findings include: 1) It was observed at 1:01PM, the paired exit doors located in hall 2 required excessive force to open Maintenance Staff A and B were present during the survey and acknowledged the finding. NFPA Standard: 7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows: (1) The opening forces for interior side-hinged or pivoted swinging door leaves without closers shall not exceed 5 lbf (22 N). (2) The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile. (3) The opening forces for horizontal-sliding door leaves in detention and correctional occupancies shall be as provided in Chapters 22 and 23. (4) The opening forces for power-operated door leaves shall be as provided in 7.2.1.9.

Based on observation and staff interview the facility failed to provide task orientated emergency lighting as required by NFPA 101 and NFPA 110. The deficient practice could leave critical areas without illumination during a disruption of normal power causing the delay of patient care. This deficiency affects all residents, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 8 and census of 6 at the time of the review. Findings include: 1) It was observed at 1:06 PM, the med room the lights are switched in halls 1 and 2, preventing the room light from illuminating in the event of a power failure. 2) It was observed at 1:12 PM, the diesel gas generator, located outside, is not provided with battery back-up emergency lighting and is not accessible to vehicle supplied illumination 3) It was observed at 1:12 PM, the automatic transfer switches, located in the main electrical room, are not provided with battery back-up emergency lighting. Maintenance Staff A and B were present during the survey and acknowledged the finding. NFPA Standard: Emergency lighting shall be provided in accordance with Section 7.9. 2012 NFPA 101, 19.2.9.1 NFPA Standard: Emergency illumination shall be provided for a minimum of 1 ½ hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (l0.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 ½ hours. A maximum-to minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 2012 NFPA 101, 7.9.2.1 NFPA Standard: The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 32.3 lux NFPA 110 (2010) 7.3.1

Based on observation, and staff interview the facility fails to maintain the smoke barrier doors. This deficient practice could prevent containment of fire and smoke, affecting all residents, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 8 and census of 6 at the time of the review. Findings include: 1) It was observed at 1:26 PM, the smoke barrier doors in hall 1 failed to close when tested, one leaf is obstructed by hitting the top of the door frame Maintenance Staff A and B were present during the survey and acknowledged the finding. NFPA Standard: Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3/4 in. NFPA 101 (2012) 19.3.7.6, 19.3.7.8,

Based on record review the facility is not conducting fire drills as required. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 8 and census of 6 at the time of the review. Findings include: 1) It was observed during records review of the previous (5) quarters of fire drills, there is no documentation verifying transmission of the fire alarm signal to the monitoring company for fire drills conducted in 2021 or 2022 Maintenance Staff A and B were present during the survey and acknowledged the finding. NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. NFPA 101 2012 19.7.1*

Based on record review and staff interview, the facility failed to assure the generator is maintained, inspected, and tested in accordance with National Fire Protection Association (NFPA) 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all residents, visitors, and staff in 3 of 3 smoke zones. The facility has a capacity of 8 and census of 6 at the time of the review. Findings include: 1) It was revealed during record review of the annual service report of the previous (2) years that there is no documentation or verification of the automatic transfer time for the diesel gas generator. 2) It was revealed during record review of the 2021 fuel testing that the diesel fuel storage has contaminates outside of the acceptable range. Maintenance Staff A and B were present during the survey and acknowledged the finding. NFPA Standard: The verification of transfer time is to be checked and documented by the generator company during the annual inspection, testing and maintenance of the generator to verify the generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) NFPA Standard: NFPA 110 2010 ed. 8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.