Hospice of Southern Kentucky

“Based on record review and interview, it was determined the facility failed to install and maintain exit signage in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 10 beds with a census of six (6) on the day of the survey. The findings include: Record review, of the exit sign inspection log on 01/14/2025 at 11:45 AM, revealed the facility failed to visually inspect exit signage for operation of illumination monthly during November and December of 2024. Interview, on 01/14/2025 at 11:46 AM with the Maintenance Supervisor, revealed the facility was not aware the exit sign inspections were not documented for November and December of 2024. The finding was verified by the Maintenance Supervisor at the time of record review and the Administrator at the exit conference on 01/14/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4 7.10.9 Testing and Maintenance. 7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3. 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.”

“Based on observation and interview, the facility failed to provide separation of hazardous areas from other areas in the facility in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 10 beds with a census of six (6) on the day of the survey. Findings include: Observation, during the building inspection tour on 01/14/2025 at 12:55 PM, revealed the Maintenance Area was over 50 square feet, used to store combustible materials such as cardboard boxes, and the door to the egress corridor would not self-close. Interview, on 01/14/2025 at 12:56 PM with the Maintenance Supervisor, revealed the facility was not aware a door closing device was required for the room. The finding was verified by the Maintenance Supervisor at the time of record review and the Administrator at the exit conference on 01/14/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1 19.3.2.1.3 The doors shall be self-closing or automatic closing”

“Based on observation and interview, it was determined the facility failed to have an approved design location under the Kitchen Hood Extinguishing System in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of two (2) smoke compartments and kitchen staff. The facility had the capacity for 10 beds with a census of six (6) on the day of the survey. The findings include: Observation, during the building inspection tour on 01/14/2025 at 12:46 PM, revealed the stove, located on the cooking line in the kitchen, was not provided with an approved method that would ensure the appliance was returned to an approved design location after it had been moved for maintenance or cleaning. Interview, on 01/14/2025 at 12:47 PM with the Maintenance Supervisor, revealed the facility was not aware of the requirement for an approved method to ensure that appliances were returned to an approved design location after maintenance or cleaning and did not have a system in place currently. The finding was verified by the Maintenance Supervisor at the time of observation and the Administrator at the exit conference on 01/14/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.3.2.5 Cooking Facilities. 19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4. 19.3.2.5.2* Where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area. 9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. Actual NFPA Standard: NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, (2011) 12.1.2 Installation. 12.1.2.1 All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer’s instructions. 12.1.2.2* Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior re-evaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire extinguishing system. 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer’s listed design manual. 12.1.2.3.1 An approved method shall be provided that will ensure that the appliance is returned to an approved design location.”

“Based on observation and interview, it was determined the facility failed to have an approved design location under the Kitchen Hood Extinguishing System in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of two (2) smoke compartments and kitchen staff. The facility had the capacity for 10 beds with a census of six (6) on the day of the survey. The findings include: Record review, of the facilitys fire alarm inspection reports for the 12-month period prior to the survey on 01/14/2025 at 11:47 AM, revealed the backup batteries in the fire alarm panel did not have documentation of a charger test and discharge test performed within the last year. Interview, on 01/14/2025 at 11:48 AM with the Maintenance Supervisor, revealed the facility was not aware the fire alarm batteries were missing documentation of testing on the fire alarm inspection report. The finding was verified by the Maintenance Supervisor at the time of record review and the Administrator at the exit conference on 01/14/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.3.4 Detection, Alarm, and Communications Systems. 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 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. Actual NFPA Standard: NFPA 72 National Fire Alarm and Signaling Code, (2010) 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.”

“Based on observation and interview the facility failed to maintain a fireplace in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 10 beds with a census of six (6) on the day of the survey. Findings include: Observation, during the building inspection tour on 01/14/2025 at 12:36 PM, revealed the fireplace located the front lobby did not have complete separation of the combustion system from the atmosphere of the occupied area and not vent connected to the outside of the facility. Interview, on 01/14/2025 at 12:37 PM with the Maintenance Supervisor, revealed the facility was unaware the fireplace wasnt installed as required. The finding was verified by the Maintenance Supervisor at the time of the observation and the Administrator at the exit conference on 01/14/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.5.2.2* Any heating device, other than a central heating plant, shall be designed and installed so that combustible material cannot be ignited by the device or its appurtenances, and the following requirements also shall apply: (1) If fuel-fired, such heating devices shall comply with the following: (a) They shall be chimney connected or vent connected. (b) They shall take air for combustion directly from the outside. (c) They shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. (2) Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.”

“Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly for each shift in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 10 beds with a census of six (6) on the day of the survey. The findings include: Record review, of the facility’s fire drill records for the 12-month period prior to the survey on 01/14/2025 at 11:30 AM, revealed the facility completed the fire drills for first (1st) and second (2nd) shifts on the same day for the second (2nd), third (3rd), and fourth (4th) quarters of 2024. Interview, on 01/14/2025 at 11:31 AM with the Maintenance Supervisor, revealed the facility was not aware that completing the fire drills on the same day for the quarter was not under varied conditions. The finding was verified by the Maintenance Supervisor at the time of record review and the Administrator at the exit conference on 01/14/2025. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.7.1.6 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.”

“Based on record review and interview, the facility failed to maintain the receptacles in patient areas in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 10 beds with a census of six (6) on the day of the survey. The findings include: Record review, of the receptacle testing records on 01/14/2025 at 12:40 PM, revealed non-hospital grade receptacles located in resident areas throughout the facility did not have annual retention and polarity testing documentation. Interview, on 01/14/2025 at 12:41 PM with the Maintenance Supervisor, revealed the facility was unaware the non-hospital grade receptacles in the resident areas required annual testing. The finding was verified by the Maintenance Supervisor at the time of record review and the Administrator at the exit conference on 01/14/2025. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2.”

“Based on observation and interview, the facility failed to maintain extension cords in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 10 beds with a census of six (6) on the day of the survey. The findings include: Observation, during the building inspection tour on 01/14/2025 at 12:25 PM, revealed an ungrounded extension cord that was plugged into a receptacle located in the family room adjacent to the fireplace. Interview, on 01/14/2025 at 12:26 PM with the Maintenance Supervisor, revealed the facility was not aware of the ungrounded extension cord plugged into the wall. 2. Observation, during the building inspection tour on 01/14/2025 at 12:27 PM, revealed an ungrounded extension cord that was plugged into a receptacle located in the family room adjacent to the couch. Interview, on 01/14/2025 at 12:28 PM with the Maintenance Supervisor, revealed the facility was not aware of the ungrounded extension cord plugged into the wall. 3. 3. Observation, during the building inspection tour on 01/14/2025 at 12:29 PM, revealed an ungrounded extension cord that was plugged into a receptacle located in the front entry area across the corridor from the family room. Interview, on 01/14/2025 at 12:30 PM with the Maintenance Supervisor, revealed the facility was not aware of the ungrounded extension cord plugged into the wall. 4. 4. Observation, during the building inspection tour on 01/14/2025 at 12:32 PM, revealed an extension cord was plugged into a Christmas tree located in resident room 105. Interview, on 01/14/2025 at 12:33 PM with the Maintenance Supervisor, revealed the facility was not aware the ungrounded extension cord could not be used for Christmas Trees. 5. 5. Observation, during the building inspection tour on 01/14/2025 at 12:34 PM, revealed an extension cord was plugged into a Christmas tree located in resident room 103. Interview, on 01/14/2025 at 12:35 PM with the Maintenance Supervisor, revealed the facility was not aware the ungrounded extension cord could not be used for Christmas Trees. The findings were verified by the Maintenance Supervisor at the time of observation and the Administrator at the exit conference on 01/14/2025. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) 10.2.4 Adapters and Extension Cords. 10.2.4.1 Three-prong to two-prong adapters shall not be permitted. 10.2.4.2 Adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted. 10.2.4.2.1 All adapters shall be listed for the purpose. 10.2.4.2.2 Attachment plugs and fittings shall be listed for the purpose. 10.2.4.2.3 The cabling shall comply with 10.2.3 10.2.3.2 Grounding Conductor. 10.2.3.2.1 Each electric appliance shall be provided with a grounding conductor in its power cord. Actual NFPA Standard: NFPA 70 National Electrical Code, (2011) 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage Reference: CMS S&C 14-46-LSC”