Every finding on record at Unity Hospice

Based on record review and staff interview, the facility failed to include required contact information in the emergency preparedness plan per 42 CFR section 418.113(c)(2). This deficient practice could affect all patients, as well as undetermined number of staff and visitors. --- Findings include:On 02/04/2026 at 11:39 am, record review of the Emergency Preparedness Plan (EPP) revealed that the contact information for the Federal, State, tribal, regional, and local emergency preparedness staff was not included in the EPP or communication plan. When asked if this contact information was available, Staff E reviewed electronic documents from her computer but was unable to locate and retrieve this information.This finding was confirmed at the time of discovery by concurrent interview with Staff D and Staff E.

Based on record review and interview, the facility did not document the monthly inspections of the exit lights in accordance with the requirements of NFPA 101 (2012 edition), sections 19.2.9.1 and 7.10.9.1. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. --- Findings include:On 02/04/2026 at 9:56 am, record review revealed monthly visual inspections for the operation and illumination of the exit lights were not documented for the past (12) months. When asked if the exit lights were visually inspected and documented each month, Staff D replied, "I check exit lights when I check extinguishers and detectors, but it is not documented."This finding was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on observation and interview, the facility failed to install supervised smoke detection in accordance with the requirements of NFPA 101 (2012 edition), sections 19.3.4, 19.3.4.2.1, and 9.6 and NFPA 72 (2010 edition), sections 17.7.3, 17.7.4, and 17.7.4.1.  This deficient practice could affect 6 of 12 patients, as well as an undetermined number of staff and visitors. --- Findings include:On 02/04/2026 at 12:47 pm, observation in the Fireplace Room B138 revealed that (2) ceiling mounted smoke detectors were located within 28-inches of the air flow of 6-inch by 24-inch air supply diffusers. One detector was located on the south side of the room, and the other was on the north side of the room. The facility had no documentation to confirm that the detector was installed per manufacturer’s recommendations.This finding was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system accordance with the requirements of NFPA 101 (2012 edition), sections 19.3.4, 9.6.1.3, and 9.6.1.5; NFPA 72 (2010 edition), sections 14.3.1, 14.4.2.2, 14.4.5, 14.6, and 14.6.2.4. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. --- Findings include:On 02/04/2026 at 9:27 am, record review of fire alarm inspection and testing revealed no documentation that the semi-annual visual inspections of initiating devices (duct detectors, electro-magnetic door hold-opens, pull stations, heat detectors, smoke detectors) or testing of the fire system batteries was performed in the past 12 months. When asked if the semi-annual inspection had been performed, Staff D replied “I do a visual inspection for any damage of devices, but I don’t document it. I do not do any battery testing.”This finding was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke in accordance with NFPA 101 (2012 edition) sections 19.3.6.3.1, 19.3.6.3.5, 19.3.2.4 and 8.7; NFPA 99 (2012 edition), sections 11.3.1, 5.1.3.3.2. This deficient practice could affect 0 of 12 patients, as well as an undetermined number of staff and visitors. --- Findings include:On 02/04/2026 at 12:30 pm, observation in the basement of the 45-minute rated fire door between the Oxygen Central Supply room and the emergency egress corridor revealed that when the door was opened and released to close, the door would not fully close and latch for (3) of (3) attempts. The basement is only accessed by an exterior door at grade, and no patients have access to the basement.This finding was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on observation, record review and interview, the agency nurse failed to follow standards of practice for disposal of patient medication in 1 of 1 inpatient observations (Patient #6) in a total of 6 observations of patient care.Findings include: --- Record review of agency policy titled "Medications-Management" dated 12/2022 revealed "Procedures: 15. Medications that are no longer needed are disposed of in accordance with accepted standards of practice."During an observation and interview with RN B on 02/04/2026 at 9:15 AM, RN B went into the locked pharmacy room and retrieved the medication bottle Atorvastatin for Patient #6 from a locked medication cart. RN B removed the label from the medication bottle and threw the label into a black medication disposal bin located behind RN B on the other side of the pharmacy room. RN B then threw the medication bottle, which was 1/4 full of white pills, into a trash bin to the right of the medication cart. RN B stated that when a patient medication is discontinued, B will throw the label into the designated medication bin and throw the medication bottle away.During an interview with Team Leader C on 02/04/2026 at 9:50 AM, Team Leader C stated, "There is a designated medication disposal box located in the pharmacy area. Controlled substances go into a Drug Buster and anything else goes into the designated medication disposal bin. Except if empty, it goes into the garbage." Team Leader C stated RN B should have put the medication bottle in the designated bin.

Based on observation, staff interview and review of maintenance records on February 4, 2026, Unity Hospice, DePere, WI failed to meet the following fire protection and building safety standards for safety to patients. --- Findings include                                 K 0293 Exit Signage - Maintenance and TestingK 0341 Fire Alarm System InstallationK 0345 Fire Alarm System - Maintenance and TestingK 0363 Corridor Doors42CFR 418.110(d) Standard: Fire Protection42CFR 418.110(e) Standard: Building Safety As a result of the above deficiency, 42 CFR Subpart 418.110 Condition of Participation: Hospices that provide inpatient care directly was NOT MET. See K-tags for details of the specific findings.

Based on record review and interview, the agency failed to follow the plan of care visit frequency orders in 2 of 27 patient (Patients #1 and #21) records reviewed. --- Findings include: Review of agency policy and procedure titled ";Plan of Care" (not dated) revealed ";Policy: 1. The patients plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessments of the patient." Review of this agencys printed process for documentation of Missed Visits revealed in part, ";Missed (Cancelled) Visits: If a patient or caregiver cancels a visit that will NOT be rescheduled, navigate to the Schedule task...double click the visit to document the reason the visit will not be completed." Record review on 02/07/2023 for Patient #1 revealed a start of care 11/25/2022 and primary diagnosis of Late Effect of Cerebrovascular Accident. Review of document titled "Care Plan" revealed under "Skilled Nursing (SN): 11/25/2022 to 12/01/2022: 2 visits every day for 7 days and 1 to 24 visits as needed. 12/01/2022 to 12/07/2022: 1 visit every day for 7 days. 12/03/2022 to 12/09/2022: 2 visits every day for 7 days. 12/10/2022 to 12/16/2022: 2 visits every day for 7 days." Review of SN visits revealed no documentation of a second SN visit conducted on 11/27/2022, 11/29/2022, 11/30/2022, 12/06/2022, and 12/08/2022. The above findings for Patient #1 were confirmed during an interview with Clinical Nurse Specialist A on 02/07/2023 at 3:45 PM. Clinical Nurse Specialist A stated, ";No visit or contact by the SN was made." Record review on 01/07/2023 for Patient #21 with a Plan of Care dated 10/05/2022-02/07/2023 revealed "Certified Nurse Assistant (CNA) order visit set: 1 visit every week for 4 weeks." During the time of 12/25/2022-12/31/2022 no CNA visit was made. During Interview with Nurse Educator I on 02/07/2023 at 3:00 PM, Nurse Educator I confirmed Patient #21 did not have a CNA visit the week of 12/25/2023-12/31/2023. When asked if the CNA documented any missed visit in the record, Nurse Educator I replied, "No there is no documentation."

Based on record review and interview, the agency staff failed to develop plans of care that were individualized to meet the patients needs in 12 of 27 patient records reviewed (Patients #3, #4, #5, #6, #7, #8, #10, #11, #13, #16, #18, and #20.) --- Findings include: Review of agency policy and procedure titled ";Plan of Care" (not dated) revealed ";Policy: The care and services provided to the patients and their families are in accordance with an individualized, written plan of care established by the hospice IDT (Interdisciplinary Team) in collaboration with the patients attending physician and, if appropriate, the patient and/or his/her representative." Review of agencys printed process for adding a plan of care template under ";Home Safety" and ";Pain" revealed that each template contains canned but customizable interventions. During an interview with Clinical Nurse Specialist A on 02/07/2023 at 1:30 PM, when asked about the template and what the asterisk means in the template provided, Clinical Nurse Specialist A replied, "The intention of the asterisk in each template is that the clinician can click on the asterisk and that is the part that can be updated to individualize to the specific area." Record review of Patient #3's Plan of Care dated 09/23/2022-12/21/2022 revealed intervention under "Problem: Home Safety, Impaired GI/GU Function, Impaired Nutrition Oral, and Pain" were generic and not individualized to meet the needs of Patient #3. Record review of Patient #4s Plan of Care dated 10/24/2022-01/21/2023 revealed intervention under ";Problem: Pain" were generic and not individualized to meet the patient needs regarding specific pain location. Examples include ";Pain: Patient uses distraction to manage pain. Patient uses repositioning to manage pain." Record review of Patient #5s Plan of Care dated 08/04/2022-11/02/2022 revealed intervention under ";Problem: Pain" were generic and not individualized to meet the patient needs regarding specific pain location. Examples include ";Pain: Patient uses distraction to manage pain. Patient uses repositioning to manage pain." Record review of Patient #6s Plan of Care dated 11/22/2022-02/19/2023 revealed intervention under ";Problem: Pain and Problem" were generic and not individualized to meet the patient needs regarding specific pain location. Example includes ";Pain: Patient uses reposition to manage pain." Record review of Patient #7's Plan of Care dated 11/01/2022-02/05/2023 revealed intervention under "Problem: Pain" were generic and not individualized to meet the needs of Patient #7. Examples include ";Pain: Patient uses distraction to manage pain. Patient uses repositioning to manage pain." Record review of Patient #8s Plan of Care dated 01/14/2023-04/14/2023 revealed intervention under ";Problem: Safety" were generic and not individualized to meet the patient needs regarding specific safety interventions specific to Patient #8. Example includes, ";Patient will remain free from falls." Record review of Patient #10's Plan of Care dated 11/25/2022-02/22/2023 revealed interventions under Problem: Safety" were generic and not individualized to meet the patient needs regarding specific safety interventions specific to Patient #10. Example includes, ";Patient will not be injured related to falls." Record review of Patient #11's Plan of Care dated 01/25/2023-04/24/2023 revealed intervention under "Problem: Pain" were generic and not individualized to meet the needs of Patient #11. Examples include ";Pain: Patient uses distraction to manage pain. Patient uses repositioning to manage pain." Record review of Patient #13's Plan of Care dated 01/07/2023-04/07/2023 revealed interventions under ";Problem: Safety" were generic and not individualized to meet the patient needs regarding specific safety interventions specific to Patient #13. Example includes ";Patient will remain free from falls." Record review of Patient #16's Plan of Care dated 11/04/2022-02/14/2023 revealed interventions under ";Problem: Safety" were generic and not individualized to meet the patient needs regarding specific safety interventions to Patient #16. Example includes, ";Patient will not be injured related to falls." Record review of Patient #18's Plan of Care dated 12/06/2022-03/05/2023 revealed interventions under ";Problem: Safety" were generic and not individualized to meet the patient needs regarding specific safety interventions to Patient #18. Example includes, ";Patient will not be injured related to falls." Record review of Patient #20's Plan of Care dated 07/06/2022-03/05/2023 revealed interventions under ";Problem: Safety" were generic and not individualized to meet the patient needs regarding specific safety interventions to Patient #20. Example includes, ";Patient will not be injured related to falls." During an interview with Nursing Educator I on 02/08/2023 at 11:45 AM, when asked how Safety Interventions are individualized, Nursing Educator I replied, "Safety recommendations change person to person, staff will remove the generic templates of what is not in the patients home." During an interview with Clinical Nurse Specialist A on 02/08/2023 at 11:45 AM, when asked how Pain Interventions are individualized, Clinical Nurse Specialist A replied, ";The pain intervention template has an asterisk and staff should enter the specific body part the patient has the pain to individualize." The above findings were confirmed on 02/08/2023 at 2:15 PM with Clinical Nurse Specialist A and Nursing Educator I.

Based on record review, observation, and interview, the agency staff failed to adhere to infection control practices related to hand hygiene and equipment cleaning in 3 of 6 patient home visit and/or facility observations conducted (Patient #10, #12, and #25). --- Findings include: Review of agency policy titled ";Infection Control-Standard and Transmission Based Precautions" dated 12/2022 revealed in part ";Procedures: 1. Hospice staff are required to use standard precautions in the care of all hospice patients. Standard precautions include but are not limited to: a. Hand hygiene before and after patient contact. d. Cleaning and disinfecting contaminated surfaces, equipment, and other objects in accordance with Center for Disease Control and Prevention (CDC) standards. 3. Equipment: a. Computer and Equipment bags: i. All reusable equipment that is carried in the bag (stethoscopes, blood pressure cuffs etc. should be wiped with a disinfectant wipe before they are returned to the bag. iii. a. Unity staff is responsible for the day-to-day upkeep, cleaning, and disinfecting of their instruments utilizing Unity provided disinfectant wipes." Review of CDC guidelines dated 2008 revealed ";4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly)." Review of ";Sani – cloth (germicidal disposable wipe)" label instructions revealed in part, ";Areas of use: Hospice. To disinfect: Allow treated surface to remain wet for two minutes. Let air dry." A home visit observation was conducted on 02/06/2023 from 2:00 PM to 3:00 PM for Patient #10. At 2:26 PM and after the use of reusable medical equipment, Registered Nurse (RN) F cleaned measuring equipment, stethoscope, and blood pressure cuff with an anti-bacterial wipe and placed these items directly in RN Fs medical bag without allowing them to dry for two minutes. A home visit was conducted on 02/07/2023 from 8:30 AM to 9:30 AM for Patient #12. At 8:50 AM and after donning gloves, Certified Nursing Assistant (CNA) J touched Patient #12's garbage can on 3 occasions, and without performing hand hygiene, performed oral/mouth cares for patient #12. At 9:15 AM CNA J completed Patient #12's shower returned to Patient #12's room, donned gloves and transferred Patient #12 to bed, changed Patient #12's garbage, and without performing hand hygiene, continued skin cares for Patient #12. During interview with Nurse Educator D on 02/07/2023 at 9:00 AM, Nurse Educator D was asked if Nurse Educator D observed any concerns with the visit for Patient #12. Nurse Educator D did not answer. Nurse Educator D was asked if Nurse Educator D saw CNA J touch the garbage can and continue with patient cares for Patient #12 without performing hand hygiene. Nurse Educator D replied, "Yes I saw that." An inpatient facility patient care observation was conducted on 02/07/2023 from 8:50 AM to 9:25 AM for Patient #25. RN C utilized a stethoscope and placed on Patient #25s skin to assess the heart, abdomen and lungs. RN C placed the stethoscope on a chair in Patient #25s room. At the end of patient care, RN C removed the stethoscope from the chair, left Patient #25s room, walked down the hallway with stethoscope in hand, walked into the nurses station, and set the stethoscope on a desk surface, without disinfecting the stethoscope prior to setting it down. RN C then obtained an anti-bacterial wipe to clean the stethoscope and did not clean the desk area once the stethoscope was removed. During an interview with Team Leader B on 02/07/2023 at 10:05 AM, when asked about the process of cleaning equipment used from patient to patient, Team Leader B replied ";They (nursing staff) have to come out of the room and go to the nurses station to clean. They have to go back to the nurses station to clean there." The above findings for Patients #10, #12, and #25 were confirmed on 02/07/2023 at 3:00 PM with Clinical Nurse Specialist A, Team Leader B, Nursing Educator I, Executive Director N, and other members of the Unity Hospice team.

Based on record review and interview, the agency nurses failed to assess the nursing needs of the patients in 5 of 27 patient records reviewed (Patients #1, #3, #5, #7 and #24) --- Findings include: Review of agency policy and procedure titled ";Plan of Care" (not dated) revealed ";Policy: 1. The patients plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessments of the patient." Review of agency policy and procedure titled ";Comprehensive Assessment-Updates" (not dated) revealed ";Policy: Unity IDT (Interdisciplinary Team) updates the comprehensive assessment and reassesses the patients response to care on a regular basis. Procedures: 1. A patients progress toward desired outcomes and response to care is reassessed as often as required by the patients condition but no less frequently than every 15 days." Record review on 02/08/2023 for Patient #1 revealed a start of care 11/25/2022 and primary diagnosis of Late Effect of Cerebrovascular Accident. Review of document titled "Care Plan" revealed under "Intervention: Assess Wound dated 11/30/2022. Unity SN (Skilled Nurse) to complete full wound assessment and measure wound to left heel and coccyx weekly. Intervention: Assess Nutrition and Weights dated 11/30/2022. Unity SN to measure patient's weight weekly. Unity SN to measure patients arm circumference of left arm every month." Review of SN visit documentation revealed the SN failed to assess Patient #1s arm circumference for the entire length of patient episode 11/25/2022 to 12/11/2022, failed to assess weights the week of 11/27/2022 and 12/04/2022, and failed to assess and measure the left heel wound and coccyx wounds the week of 12/04/2022. During interview with Nursing Educator I on 02/08/2023 at 10:00 AM, when asked if Patient #1 had documented weights, arm circumferences and wound assessed, Nursing Educator I replied ";Weights and arm circumferences do not exist. They are not there. No additional assessments or measurements of wound on the coccyx or heel." Record review on 02/08/2023 for Patient #3 revealed a start of care 09/23/2022 and primary diagnosis of Chronic obstructive pulmonary disease (COPD). Review document titled "Care Plan" revealed under "Intervention: Assess Nutrition and Weights dated 09/28/2022, Registered Nurse (RN) to measure patient's weight every comprehensive visit." Review of RN Comprehensive Visit dated 09/28/2022 revealed the RN failed to assess the weight for Patient #3. During an interview with Nursing Educator I on 02/08/2023 at 11:42 AM, when asked if Patient #3 had a documented weight for the Nursing Comprehensive visit dated 09/28/2023, Nursing Educator I replied, "it's not there." Record review on 02/08/2023 for Patient #5 revealed a start of care 08/04/2022 and primary diagnosis of Heart Failure and Failure to Thrive. Review of document titled "Care Plan" revealed under "Problem: Cardiac Function: Goal: Absence of fluid volume deficit and signs and symptoms. Patient #5 to have left lower extremity less that 2+ (edema). Unity SN to assess progress towards edema (symptom) goal at each routine visit and as needed." Review of SN routine visit documentation revealed the SN failed to assess edema on 09/12/2022, 09/28/2022, 10/25/2022, and 11/07/2022. During interview with Clinical Nurse Specialist A on 02/08/2023 at 2:00 PM, when asked about the missing SN edema assessments on 09/12/2022, 09/28/2022, 10/25/2022, and 11/07/2022, Clinical Nurse Specialist A replied ";No, I am not able to find those." Record review on 02/08/2023 for Patient #7 revealed a start of care 10/27/2022 and primary diagnosis of Osteomyelitis of the Pelvis/Spinal Bifida. Review of document titled "Care Plan" revealed under "Intervention: Assess Nutrition and Weights dated 11/10/2022. RN to measure patient's arm circumference to the right arm with comprehensive visit." Review of RN comprehensive documentation revealed the RN failed to assess the arm circumference for Patient #7 on 01/30/2023, 01/17/2023, 12/30/2022, 12/02/2022, 11/02/2022. During an interview with Nursing Educator I on 02/08/2023 at 12:45 PM, when asked if Patient #7 had documented Arm Circumference for 01/30/2023, 01/17/2023, 12/30/2022, 12/02/2022, or 11/02/2022, Nursing Educator I replied, Patient #7 was young and often refused certain nursing assessments, Nursing Educator I asked if the refusal should be documented and where, Nursing Educator I replied, "yes, normally under the narrative note." Confirmed with Nursing Educator I that the missing arm measurements were not done or documented in a narrative note. Record review on 02/08/2023 for Patient #24 revealed a start of care 01/26/2023 and primary diagnosis of Protein Calorie Malnutrition. Review of document Titled "Care Plan" revealed under "Assess Nutrition and Weights dated 01/29/2021. RN to measure patient's weight every 2 weeks and as needed. RN to measure patient's arm circumference of right arm every 2 weeks." Review of RN comprehensive documentation revealed the RN failed to assess weights and arm circumference to the right arm for Patient #24 on 10/13/2022, 10/27/2022, 11/17/2022, 11/23/2022, 12/26/2022, and 01/19/2023. During interview with Nursing Educator I on 02/08/2023 at 10:40 AM, when asked if Patient #24 had documented Arm Circumference and Weights documented every 2 weeks, Nursing Educator I replied, "I do not see it documented every two weeks." Nursing Educator I was asked why Patient #24's Interdisciplinary Team notes documented a weight and arm circumference every two weeks, but the RN comprehensive visit notes are missing the weight and arm circumference, Nursing Educator I replied, "They should be documented in the RN comprehensive notes."

A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on February 07, 2023. Unity Hospice was found to NOT be in substantial compliance with the following applicable regulations for a Hospice facility participation in Medicare-Medicaid:42 CFR Subpart 418.110 (c) - Physical Environment was NOT METFindings include:The facility was found to contain the following deficiencies.K 0353 Sprinkler System - Maintenance and TestingK 0712 Operating Features - Fire DrillsK 0918 Electrical Systems - Essential Electric SystemsPlease refer to the full description at the cited K-tags. Due to the accumulative effect of these citations safety of the patients, visitors, and staff was not maintained in accordance with the Life Safety Code (NFPA 101-2012).

A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on February 07, 2023. Unity Hospice was found to NOT be in substantial compliance with the following applicable regulations for a Hospice facility participation in Medicare-Medicaid:42 CFR Subpart 418.110(d) - Fire Protection was NOT METFindings include:The facility was found to contain the following deficiencies.K 0353 Sprinkler System - Maintenance and TestingK 0712 Operating Features - Fire DrillsK 0918 Electrical Systems - Essential Electric SystemsPlease refer to the full description at the cited K-tags. Due to the accumulative effect of these citations safety of the patients, visitors, and staff was not maintained in accordance with the Life Safety Code (NFPA 101-2012).

Based on record review and interview, the agency staff failed to ensure that the hospice plans of care for patients residing in skilled nursing facilities (SNF), Community-Based Residential Facilities (CBRF), and Assisted Living Facilities (ALF) clearly delineated which provider was responsible for which functions within the plan of care in 12 out 12 of patients (Patient's #4, #5, #10, #11, #12, #13, #14, #17, #18, #21, #23, and #24) receiving hospice care in skilled nursing facilities, in a total of 27 patient records reviewed. --- Findings Include: Review of agency policy and procedure titled ";Hospice Care for Nursing Facility Resident- Hospice Plan of Care" (not dated) revealed ";Procedures: 3. The plan of care for the facility patient identifies the care and services that are needed and specifically identifies which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care." The agency's contract titled "Hospice-Skilled Nursing Facility Agreement, and Hospice Assisted Living Facility Agreement" dated 2/11/2020, revealed in part under "2.4 Hospice Plan of Care (a.) the Hospice Plan of Care shall specifically identify which provider is responsible for performing the care and services included in Hospice Plan of Care." Record review of Patient #4s Plan of Care dated 10/24/2022-01/21/2023 revealed Patient #4 resided in an ALF. Patient #4s Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #5's Plan of Care dated 08/04/2022-11/02/2022 revealed Patient #5 resided in a CBRF. Patient #5's Plan of Care did not delineate which provider was responsible for interventions on the Plan of Care. Record review of Patient #10's Plan of Care dated 11/25/2022-02/22/2023 revealed Patient #10 resided in a SNF. Patient #10's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #11's Plan of Care dated 01/25/2023 revealed Patient #11 resided in a CBRF. Patient #11's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #12's Plan of Care dated 01/22/2023-04/22/2023 revealed Patient #12 resided in a SNF. Patient #12's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #13's Plan of Care dated 01/07/2023-04/07/2023 revealed Patient #13 resided in a SNF. Patient #13's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #14's Plan of Care dated 11/11/2022-02/09/2023 revealed Patient #14 resided in a SNF. Patient #14's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #17's Plan of Care dated 11/14/2022-02/11/2023 revealed Patient #17 resided in an ALF. Patient #17's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #18's Plan of Care dated 12/06/2022-03/05/2023 revealed Patient #18 resided in a SNF. Patient #18's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #21's Plan of Care dated 10/05/2022 – 02/07/2023 revealed Patient #21 resided in an ALF. Patient #21's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #23's Plan of Care dated 12/10/2022-03/09/2023 revealed Patient #23 resided in a SNF. Patient #23's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. Record review of Patient #24's Plan of Care dated 01/16/2023-03/16/2023 revealed Patient #24 resided in an ALF. Patient #24's Plan of Care did not delineate which provider was responsible for which interventions on the Plan of Care. The above findings were reviewed and confirmed during an interview with Clinical Nurse Specialist A and Nursing Educator I on 02/08/2023 at 2:15 PM.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, NFPA 25 - 2011 edition, Sections 5.2.1, 5.2.1.1.1, 13.2.7.2, 13.3.2.1.1, 13.6.1, 13.6.1.1.1, 13.4.2.1, 14.2.1 & Table 5.1.1.2, 13.1.1.2. This deficient practice could affect 4 of 7 patients and an undetermined number of staff and visitors. Findings include: On 02/07/2023 at 11:55 am, observation revealed in the Med Room off of the Nurses Station that the cover for a concealed sprinkler in the ceiling tile was missing leaving a gap through the ceiling tile. This gap in the ceiling does not duplicate the tight conditions that were used in the sprinkler UL certification test. This deficient practice was confirmed by Staff K at the time of discovery.

Based on record review and interview, the facility did not conduct fire drills as required by NFPA 101 (2012 edition), 19.7.1.6., to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency had the potential to affect all 7 patients and an undetermined number of staff and visitors. Findings include: On 02/07/2023 at 10:55 am, record review revealed that the facility fire drill records did not indicate any signal transmission to the monitoring company for any of the night time fire drills. This deficient practice was confirmed by Staff K at the time of discovery.

Based on record review and interview, the facility did not perform testing and maintenance of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3; and NFPA 110 (2010 edition) Sections 8.3.7, 8.4.1, 8.4.2, 8.4.6 & 5.6.4.5.1. This deficient practice could affect all 7 patients and an undetermined number of staff and visitors. Findings include: On 02/07/2023 at 12:15 pm, review of documents revealed no letter of reliability for the natural gas fuel source from a gas supplier was on file. This deficient practice was confirmed by Staff K, L, M, N and O at the time of discovery.