Every finding on record at St Augustine Manor

Based on personnel file review, Centers for Disease Control and Prevention (CDC) guidance, and staff interview, the facility failed to complete a two step Mantoux test upon hire in accordance with the CDC guidance for ten (Staff B, D, E, F, G, H, I, J, K and L) of 18 personnel reviewed. The facility's census at the time of the survey was 98. Findings include: Review of the CDC guidance titled "TB Screening and Testing of Health Care Personnel," updated March 8, 2021, revealed TB screenig and testing of helath care personnel is reommended as part of a TB infection control plan. All health care personnel should be screened for TB upon hire. TB screening is a process that includes a TB test. Under Baseline Testing the guidance states: If the Mantoux tuberculin skin test is used to test health care personnel upon hire, two-step testing should be used. Review of the personnel files for Staff B, D, E, F, G, H, I, J, K and L were reviewed on 03/10/22. The files did not contain a Mantoux two step test upon hire. Interview on 03/10/22 at approximately 11:20 AM, Staff A reported the facility thought the staff only need a one-step test upon hire and confirmed Staff B, D, E, F, G, H, I, J, K and L did not have a two step Mantoux test upon hire.

Based on observation, staff interview, and documentation review, the facility failed maintain functional test with the emergency lighting (K291), failed to conduct semi-annual visual inspections of the initiating device of the fire alarm system (K345), failed to maintain sprinkler head installed in laundry chute (K353), failed to ensure corridor doors latched (K363), failed to maintain smoke/fire barrier walls (K372), failed to maintain smoke/fire barrier (K761), and failed to maintain emergency standby generator (K918).

Based on observation, staff interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients of the inpatient unit receiving services. The inpatient census was 16. Findings included: Refer to citations at: K-291 failed to maintain functional test with the emergency lighting K-345 failed t to conduct semi-annual visual inspections of the initiating device of the fire alarm system K-353 failed to maintain sprinkler head installed in laundry chute K-363 failed to ensure corridor doors latched K-372 failed to maintain smoke/fire barrier walls K-761 failed to maintain smoke/fire barrier doors K-918 failed to maintain emergency standby generator. Surveyor: Ziegler, Erick

Based on medical record review, contract review, and staff interview, the facility failed to provide a skilled nursing facility the most recent hospice plan of care for one (Patient #2) of one patients reviewed at a skilled nursing facility. The facility has 37 patients at a skilled nursing facility. Findings include: Review of the facility contract with Facility B, effective 11/26/08, revealed under Plan of Care: Hospice, in consultation with the Facility, shall develop the plan of care specifying information pertinent to the resident's treatment. The plan will be updated bi-weekly by the hospice team. The Hospice registered nurse will review changes with the Facility's designee. After an initial conference with a representative from the Facility and Hospice, a mutually agreeable plan of care will be developed and maintained. This plan of care will be consistent with the Hospice plan of care. Required changes will be reviewed with the Hospice nurse, nursing supervisor or the Hospice Coordinator and the Facility designee(s). Review of the medical record for Patient #2, who resided at Facility B, on 03/08/22 at 2:08 PM. revealed the most recent plan of care in the medical record was for the certification period of 09/07/21 through 12/05/21. Interview with Staff M at the time of the record review confirmed Patient #2's most recent plan of care was not provided to the skilled nursing facility.

Based on record review and staff interview, the facility failed to maintain emergency lighting per NFPA 101-2012 Edition, Section 7.9*. This had the potential to affect all 16 patients at the facility. Findings include: Record review of the life safety documentation on 03/08/22 at approximately 11:00 A.M. revealed there was no documentation the emergency lighting by each designated exit had been checked for proper lux and duration when the 125-kilowatt diesel generator had been tested. Interview with Maintenance Director #1 at the time of the documentation review verified the finding. Maintenance Director #1 stated the lights by the exits were tied to the generator and the generator "took over the building." NFPA 101-2012 Edition, Section 7.9 Emergency Lighting. NFPA 101-2012 Edition, Section 7.9.1 General. NFPA 101-2012 Edition, Section 7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following: (1) Buildings or structures where required in Chapters 11 through 43 (2) Underground and limited access structures as addressed in Section 11.7 (3) High-rise buildings as required by other sections of this Code (4) Doors equipped with delayed-egress locks (5) Stair shafts and vestibules of smokeproof enclosures, for which the following also apply: (a) The stair shaft and vestibule shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment. (b) The standby generator shall be permitted to be used for the stair shaft and vestibule emergency lighting power supply. (6) New access-controlled egress doors in accordance with 7.2.1.6.2 NFPA 101-2012 Edtion, Section 7.9.2.1* Emergency illumination shall be provided for a minimum of 11?2 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 (10.8 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 11?2 hours. A maximum-to- minimum illumination uniformity ratio of 40 to 1 shall not be needed. NFPA 101-2012 Edition, Section 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)*The test interval shall be permitted to be extended be- yond 30 days with the approval of the the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11?2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101-2012 Edition, Section 7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided. (2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine. (3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator. (4) A visual inspection shall be performed at intervals not exceeding 30 days. (5) Functional testing shall be conducted annually for a minimum of 11?2 hours. (6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 11?2-hour test. (7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101-2012 Edition, Section 7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided. (2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine. (3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11?2 hours. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3). (5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

Based on record review and staff interview, the facility failed to conduct semi-annual visual inspections of the initiating devices per the requirements of NFPA 101 - 2012 Edition, Sections 19.3.4 and 9.6 and NFPA 72 - 2010 Edition, Sections 14.3, 14.3.1, 14.4.5, 14.4.5.3.1,14.4.5.3.2 and Table 14.3.1. This had the potential to affect all 16 patients at the facility. Findings include: A review of the life safety documentation on 03/08/22 at approximately 11:00 A.M. revealed there was no semi-annual visual inspection of the initiating devices. Interview with Maintenance Director #1 at the time of the document review verified the finding. NFPA 101-2012 Edition, Section 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 101-2012 Edition, Section 19.3.4 Detection, Alarm, and Communications Systems. NFPA 101-2012 Edition, Section 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. NFPA 72-2010 Edition, Section 14.3 Inspection. NFPA 72-2010 Edition, Section 14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.

Based on observation and staff interviews, the facility failed to maintain a sprinkler system per NFPA-25 2011 Edition, Section 5.2.1.1.1*. This had the potential to affect all 16 patients on the inpatient unit. Observation during the tour with Maintenance Director (MD) #1 on 03/08/22 between 2:00 P.M. and 3:15 P.M. revealed the sprinkler head installed atop the laundry chute located on the third floor was corroded and dusty. Interview on 03/08/22 at the time of the observtion with MD #1 verified the finding. NFPA-25 2011 Edition, Section 5.2.1.1.1* states, sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

Based on observation and interview, the facility failed to ensure corridor doors would close and latch to resist the passage of smoke per the requirements of NFPA 101-2012 Edition, Section 19.3.6.3.1*. This affected Room 205, Room 211, the Ice Room, and the Nurses' Station doors. Findings include: Observation during the tour with Maintenance Director (MD) #1 on 03/08/22 between 2:00 P.M. and 3:15 P.M. revealed the following doors on the second floor did not latch: Room 205, Room 211, Ice Room, and Nurses' Station. The doors were closed three times to close position and did not latch each time. Interview with MD #1 at the time of the observation verified the finding. NFPA 101-2012 Edition, Section 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13.4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes 19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following: (1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to comply with 19.3.6.3.1. (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. NFPA 101-2012 Edition, Section 19.3.6.3.3 Compliance with NFPA 80, Standard for Fire Doors and Other Opening Protectives, shall not be required. NFPA 101-2012 Edition, Section 19.3.6.3.4 A clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors. NFPA 101-2012 Edition, Section 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbs (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.

Based on observations and staff interview, the facility failed to maintain the smoke/fire barrier walls per NFPA 101-2012 Edition, Section 19.3.7.3 and 8.5.6.2. This had the potential to affect all 16 patients at the facility. Findings include: Observation during the tour with Maintenance Director (MD) #1 on 03/08/22 at approximately 2:00 P.M. through 3:15 P.M. revealed the following on the ground floor, there was a two inch pipe passing through the smoke/fire barrier wall above the designated exit near the morgue. On the ground floor there were five irregular holes measuring two inches filled with orange foam located above the designated exit by the elevator adjacent to the laundry. Interview with MD #1 at the time of the observation verified the finding. NFPA 101-2012 Edition, Section 19.3.7.3 states, Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1.2-hour fire-resistance rating unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. NFPA 101-2012 Edition, Section 8.5.6.2 states, Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/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.

Based on record review, observation, and staff interview, the facility failed to ensure smoke and fire door assemblies are tested per the NFPA 101-2012 Edition, Section 8.3.3.1, NFPA 80-2010 Edition, Section 5.2 and 5.2.1. This had the potential to affect all 16 patients at the facility. Findings include: Review of records on 03/08/22 at 11:00 A.M. revealed there was no documentation fire-rated doors installed on the smoke /fire barrier walls at each exit and in the corridors were inspected on an annual basis. Observation during a tour with Maintenance Director (MD) #1 on 03/08/22 between 2:45 P. M and 3:15 P.M. revealed a fire-rated door installed at each exit on each floor, and on cross corridor double-hung door attached to the fire alarm system. Interview with MD #1 at the time of the observation verified the finding. NFPA 80-2010 Edition, Section 5.2.1*states, fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 101-2012 Edition, Section 8.3.3.1 states, openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills per the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

Based on record review and interview, the facility failed to maintain diesel generator per NFPA 110-2010 Edition, Section 8.3.8, NFPA 110-2010 Edition, Section 8.4.2*. This had the potential to affect all 16 patients at the facility. Findings include: Record review of the life safety documentation on 03/08/22 at approximately 11:00 A.M. revealed the 125-kilowatt (kW) diesel generator had been tested on a weekly and monthly basis. The monthly records did not state if the generator had reached at least 30 percent of the nameplate kW rating to determine if it needed to be tested on an annual basis under supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and not less than 75 percent of the EPS nameplate kW rating for one continuous hour for a total test duration of not less than one and a half continuous hours. Also, the generator had no documentation the diesel fuel had been tested on an annual basis. Interview with Maintenance Director #1 at the time of the document review verified the finding. NFPA 110-2010 Edition, Section 8.3.8 states, a fuel quality test shall be performed at least annually using tests approved by ASTM standards. NFPA 110-2010 Edition, Section 8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the Manufacturer (2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating NFPA 110-2010 Edition, Section 8.4.2.3 Diesel-powered EPS installations 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. NFPA 110-2010 Edition, Section 8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement.