Casa De La Luz Hospice

“Based on record review it was determined that the facility failed to perform the monthly inspection for the facility’s sprinklers systems. Failing to perform the required inspections may cause harm to patients and staff NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. “Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.” Section 9.7.5 “All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, “Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems.” NFPA 25, 2011 Edition, “Water Based Extinguishment Systems,” requires monthly, quarterly and annual testing of automatic sprinkler systems. Findings Include: Observations while on tour February 6, 2024, revealed the facility failed to show proof of monthly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems. Employee #1 confirmed during the exit conference that the facility failed to conduct the required monthly testing of the sprinkler systems.”

“Based on observation, interview, and record review it was determined the facility failed to inspect and maintain the facility’s fire /smoke dampers or fusible links. Failing to inspect and maintain the facility’s smoke dampers may cause harm to the patients and staff. NFPA 101 Life Safety Code, 2012 Edition Chapter 21, section 21.5.2.1 “Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture’s specifications” Section 9.2.1 “ Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment.” Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A.” “Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective’s. NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other opening Protective’s. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective’s. NFPA 80 Standard for Fire Doors and Other opening Protective’s Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years. Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would effect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective’s. NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective’s Chapter 6 Installation, Testing and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except hospitals, where the frequency shall be every 6 years. Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11 Section 6.6 Maintenance. Section 6.6.1 Any reports of abrupt changes in airflow or noise from the duct system shall be investigated to verify that it is not related to damper operation. Section 6.6.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer. Section 6.6.3 if the damper is not operable, repairs shall begin as soon a s possible. Section 6.6.4 Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.6.5 Smoke damper actuation shall be initiated at a time interval recommended by the actuator manufacturer. Section 6.6.6 All maintenance shall be maintained and records shall be retained in accordance with 6.5.11 and 6.5.12. Findings Include: During the review of the facility documentation conducted on February 6, 2024, revealed the facility had fire or smoke dampers, but no documentation was found indicating that the smoke dampers were maintained in the past four years. The Administrator confirmed during the exit conference that the facility failed to test the HVAC dampers every four years.”

“Based on walkdown observations the facility failed to make the nurse call buttons available to patients who may have fallen in the restroom, or from the bed. Failing to make nurse call stations available during a patients fall could cause a patient to lay on the floor with out the ability to reach the button for assistances from the medical staff which could result in injury or death. NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 7 Information Technology and Communications Systems for Health Care Facilities. 7.3.3.1 Nurse Call Systems. 7.3.3.1.1 General. The nurse call systems shall communicate patient and staff calls for assistance and information in health care facilities. The nurse call systems shall be the audiovisual type and listed for the purpose.7.3.3.1.1.1 The nurse call systems shall provide for communication of patient and staff calls for assistance and information, medical device alarms, and patient safety and security alarms.7.3.3.1.2 Patient Area Call Station. Each patient bed location shall be provided with a calling device. Not more than two calling devices, serving adjacent beds, shall be served by a single audiovisual call station providing two-way voice communication. 7.3.3.1.3 Signals. Activation of a patient bed calling device shall cause visual signal activation in the corridor at the patient room door, the associated nursing station, the calling station, and associated nursing unit support areas, including medication, nourishment, charting, storage, and exam/treatment rooms and clean and soiled linen storage areas. 7.3.3.1.4 Additional visual signals shall be provided at corridor intersections where individual patient door signals are not directly visible from the central nursing station. 7.3.3.1.6 Emergency Call. Each calling station shall be capable of initiating a visual and audible emergency signal, distinct from the regular nurse call signal, that can be turned off only at that station. The emergency call shall activate an annunciator at the nearest associated nursing station and a visual signal in the corridor at the patient room door and at other locations as directed by the facility. 7.3.3.1.6.1 Emergency calling devices shall be provided at each inpatient toilet, bath, shower, or sitz bath and shall be accessible to a patient lying on the floor. A pull cord shall be permitted to be used for this access. 7.3.3.1.6.2 Emergency calling devices shall be provided in outpatient and treatment areas where patients can be incapacitated. 7.3.3.1.6.3 Emergency branches calling devices shall be provided in patient toilet rooms in imaging suites, renal dialysis units, and similar areas. Findings include; Observations while on tour February 6, 2024, revealed the pull cords in patients rooms, and all restrooms where not trimmed to fit and were then wrapped around the call box and tied with a tie wrap to keep them off the floor thus preventing a person laying on the floor from reaching the cord to activate to nurse call switch. Employee # 1 confirmed during the tour that the cards were tied and not available for patient use during an emergency. 7.3.3.1 Nurse Call Systems. 7.3.3.1.1 General. The nurse call systems shall communicate patient and staff calls for assistance and information in health care facilities. The nurse call systems shall be the audiovisual type and listed for the purpose. 7.3.3.1.1.1 The nurse call systems shall provide for communication of patient and staff calls for assistance and information, medical device alarms, and patient safety and security alarms. 7.3.3.1.1.2 Supplemental features shall be permitted to include call initiation to alphanumeric pagers and other wireless devices carried by health care facility staff. 7.3.3.1.2 Patient Area Call Station. Each patient bed location shall be provided with a calling device. Not more than two calling devices, serving adjacent beds, shall be served by a single audiovisual call station providing two-way voice communication. 7.3.3.1.3 Signals. Activation of a patient bed calling device shall cause visual signal activation in the corridor at the patient room door, the associated nursing station, the calling station, and associated nursing unit support areas, including medication, nourishment, charting, storage, and exam/treatment rooms and clean and soiled linen storage areas. 7.3.3.1.4 Additional visual signals shall be provided at corridor intersections where individual patient door signals are not directly visible from the central nursing station. 7.3.3.1.5 A visual signal indication shall be provided at each calling station indicating voice circuit operation. 7.3.3.1.6 Emergency Call. Each calling station shall be capable of initiating a visual and audible emergency signal, distinct from the regular nurse call signal, that can be turned off only at that station. The emergency call shall activate an annunciator at the nearest associated nursing station and a visual signal in the corridor at the patient room door and at other locations as directed by the facility. 7.3.3.1.6.1 Emergency calling devices shall be provided at each inpatient toilet, bath, shower, or sitz bath and shall be accessible to a patient lying on the floor. A pull cord shall be permitted to be used for this access. 7.3.3.1.6.2 Emergency calling devices shall be provided in outpatient and treatment areas where patients can be incapacitated. 7.3.3.1.6.3 Emergency branches calling devices shall be provided in patient toilet rooms in imaging suites, renal dialysis units, and similar areas.”

“Based on Record Review and Interview the facility failed to properly document weekly generator testing of the generator battery. Failure to test, inspect battery voltage weekly could result in harm to patients during emergency system failures. NFPA 101 Life Safety Code, 2012, Chapter19, Section 19.7.6 “Maintenance and Testing (See 4.6.12) Section 4.6.12.2 “ Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.” NFPA 99 “HEALTH CARE FACILITIES” 2012 Edition, Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) “Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 “Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 8, Section 8.4.2 “Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes... Findings Include: Observations while on tour February 6, 2024, revealed the facility to document the continuity or conductivity tests on the generators. Employee # 1 acknowledged during the exit conference on February 6, 2024 the facility failed to document the continuity or conductivity tests on the generators.”

“Based on observation the facility were storing oxygen in a room not rated for oxygen storage. Failing to store O2 in a non-rates room could cause harm to the patients if oxygen concentrations allowed O2 to combine with other combustibles and cause a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 11 Section 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 11 Section 11.3.2.3 Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles materials by one of the following: (1) Minimum distance 20 feet (2) Minimum distance of 1.5m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.93) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour. NFPA 99 2012 Edition Standard for Health Care Facilities.” Chapter 5 Section 5.1.3.3.2 Design and Construction. Section 5.1.3.3.2 (5) They shall be in compliant with NFPA 70 National Electrical Code, for ordinary locations. Locations for central supply systems and the storage of positive -pressure gases shall meet the following requirements. Section 5-1.3.3.2 (5) Electrical devices should be physically protected, such as by use of protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing damage to the cylinders or containers. The device could be located at or above finished floor 1.5 m (5 ft) or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device required by this section . Section 5.1.3.3.2 (10) They shall protect electrical devices from physical damage. 11.3.1 * Storage for nonflammable gases equal to or greater than 85 m3 (3000 ft3) at STP shall comply with 5.1.3.3.2 and 5.1.3.3.3. 11.3.2 * Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3. Section 11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. Section 11.3.2.2 Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor. Section 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1∕ 2 hour. Findings include: Observation while on tour Feb 6 2024 revealed, oxygen was being stored a room titled “medication room” the room construction was not rated for oxygen storage this room had over 30 cu ft. of oxygen. Other combustible items were also stored in the room. The room was being used to distribute O2 for the entire Hospice. Employee # 1 confirmed during the exit conference conducted on Feb 6 2024 that oxygen was being stored improperly in the above listed area.”