Hospice of Hope Inc.

“Based on record review and interview, the facility failed to maintain an Emergency Preparedness Program (EPP) in accordance with the Code of Federal Regulations (CFR) State Operations Manual (SOM), Appendix Z. 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 eight (8) beds with a census of five (5) on the day of the survey. The findings include:Record review, of the facilities’ EPP on 02/24/2026 at 1:56 PM, revealed the facility failed to review and update the Emergency Preparedness Policies and Procedures on a bi-annual basis as required. The facility last reviewed the EPP Policies and Procedures on 09/08/2023.Interview, on 02/24/2026 at 1:58 PM with the Inpatient Coordinator, revealed the facility was not aware the EPP Policies and Procedures had not been reviewed bi-annually.The finding was verified by the Administrator at time of record review and at the exit conference on 02/24/2026.”

“Based on record review and interview, the facility failed to provide documentation for the testing of the emergency battery lighting in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect all battery powered emergency lights, staff, and all residents. The facility had the capacity for eight (8) beds with a census of five (5) on the day of the survey. The findings include:Record review, of the emergency lighting documentation for the 12 months prior to the survey on 02/24/2026 at 2:40 PM, revealed the facility failed to conduct the 90-minute annual testing of the emergency battery lighting located throughout the facility. Interview, on 02/24/2026 at 2:41 PM with the Maintenance Director, revealed the facility was not aware of the requirements for the 90-minute annual testing of emergency battery lighting. The finding was verified by the Maintenance Director at the time of record review and by the Inpatient Coordinator at the exit conference on 02/24/2026. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.7.9.2.1* Emergency illumination shall be provided for a minimumof 1-1/2 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 exceeded.7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systemsshall 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 beyond 30 days with the approval of the authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1 1/2 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.”

“Based on observation and interview, the facility failed to ensure portable space heaters used in the facility were in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect three (3) portable space heating devices, staff, and three (3) residents. The facility had the capacity for eight (8) beds with a census of five (5) on the day of the survey. The findings include: 1). Observation, during the building inspection tour on 02/24/2026 at 11:28 AM, revealed the facility failed to provide documentation that a heat-producing electrical fireplace located in the Family Room area had a heating element that did not exceed 212 degrees Fahrenheit. Interview, on 02/24/2026 at 11:29 AM with the Maintenance Director, revealed the facility was aware of the requirements for portable heaters but was not aware that the electric fireplace had a functional heat producing element.2). Observation, during the building inspection tour on 02/24/2026 between 11:50 AM and 11:52 AM, revealed the facility failed to provide documentation that two (2) heat producing portable space heaters located in the Care Center Coordinator Office and the Staff Office had heating elements that did not exceed 212 degrees Fahrenheit. Interview, on 02/24/2026 at 11:53 AM with the Maintenance Director, revealed the facility was aware of the requirements for portable heaters but was not aware the portable space heaters were in the facility.The findings were verified by the Maintenance Director at the time of observation and the Inpatient Coordinator at the exit conference on 02/24/2026.Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.7.8 Portable Space-Heating Devices. Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:(1) Such devices are used only in nonsleeping staff and employee areas.(2) The heating elements of such devices do not exceed 212°F (100°C).”

“Based on observation and interview, it was determined the facility failed to provide oxygen storage in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) oxygen storage room, staff, and two (2) residents. The facility had the capacity for eight (8) beds with a census of five (5) on the day of the survey. The findings include:Observation, during the building inspection tour on 02/24/2026 at 11:13 AM, revealed the Facility Oxygen Storage Room had 15 oxygen E-type tanks stored with no natural ventilation or mechanical exhaust ventilation installed. Interview, on 02/24/2026 at 11:14 AM with the Maintenance Director, revealed the facility was not aware the ventilation of oxygen was required. The finding was verified by the Maintenance Director at the time of observation and the Inpatient Coordinator at the exit conference on 02/24/2025.Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012)9.3.7.5 Indoor storage or manifold areas and storage or manifold buildings for medical gases and cryogenic fluids shall be provided with natural ventilation or mechanical exhaust ventilation in accordance with 9.3.7.5.1 through 9.3.7.8.”

“Based on record review and interview, the facility failed to develop a Risk Assessment in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of one (1) Risk Assessment, staff, and all residents. The facility had the capacity for eight (8) beds with a census of five (5) on the day of the survey.Findings include: Record review, of the NFPA 99 Risk Assessment Log for the 12 months prior to the survey on 02/24/2026 at 2:06 PM, revealed the facility had failed to perform a NFPA 99 Risk Assessment.Interview, on 02/24/2026 at 2:07 PM with the Maintenance Director, revealed the facility was unaware a NFPA Risk Assessment was required for the facility. The finding was verified by the Maintenance Director at the time of record review and the Inpatient Coordinator at the exit conference on 02/24/2026.Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) Chapter 4 Fundamentals 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code. 4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code. 4.1.2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code. 4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code. 4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code. 4.2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure. 4.3 Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11.”

“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 all non-hospital grade receptacles, staff, and all residents. The facility had the capacity for eight (8) beds with a census of five (5) on the day of the survey. The findings include:Record review, of the plug retention testing records on 02/24/2026 at 2:12 PM, revealed non-hospital grade receptacles located in resident areas throughout the facility did not have annual retention and polarity testing. Interview, on 02/24/2026 at 2:13 PM with the Maintenance Director, revealed the facility was not aware the non-hospital grade receptacles in the resident areas required annual testing.The finding was verified by the Maintenance Director at the time of record review and by the Inpatient Coordinator at the exit conference on 02/24/2026. 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 interview and record review, it was determined the facility failed to perform testing for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of one (1) emergency generator, staff, and all residents. The facility had the capacity of eight (8) beds with a census of five (5) on the day of the survey. The findings include:1). Record Review, of the Emergency Generator maintenance log for the 12 months prior to the survey on 02/24/2026 at 2:00 PM, revealed the emergency generator for the facility did not have documentation indicating the generator had been visually inspected weekly during the 12 months prior to the survey. Interview, on 02/24/2026 at 2:01 PM with the Maintenance Director, revealed the facility was unaware the weekly visual inspections needed to be documented. 2). Record Review, of the Emergency generator maintenance log for the 12 months prior to the survey on 02/24/2026 at 2:02 PM, revealed the emergency generator for the facility did not have documentation indicating the diesel emergency generator had received annual load bank testing during the past 12 months. Interview, on 02/24/2026 at 2:03 PM with the Maintenance Director, revealed the facility was not aware the annual load bank testing was required, and the last three (3) year load bank test was performed in 2021.The findings were verified by the Maintenance Director at the time of observations and the Inpatient Coordinator at the exit conference on 02/24/2026.Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012)6.5.4 Administration (Type 2 EES).6.5.4.1 Maintenance and Testing of Essential Electrical System.6.5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.6.5.4.1.1.2 Inspection and Testing. Generator sets shall be inspected and tested in accordance with 6.4.4.1.1.3.6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, Chapter 8.Actual NFPA Standard: NFPA 110 Standard for Emergency and Standby Power Systems, (2010) 8.3 Maintenance and Operational Testing.8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.8.3.4.1 The permanent record shall include the following:(1) The date of the maintenance report(2) Identification of the servicing personnel(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced(4) Testing of any repair for the time as recommended by the manufacturer8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.8.4 Operational Inspection and Testing.8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.8.4.1.1 If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, providing the same record as required by 8.3.4.8.4.2* 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 rating8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.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.”

“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 one (1) room, staff, and two (2) residents. The facility had the capacity for eight (8) beds with a census of five (5) on the day of the survey. The findings include:Observation, during the building inspection tour on 02/24/2026 at 11:30 AM, revealed two (2) lamps plugged into an ungrounded extension cord being used as a substitute for the fixed wiring of the structure located behind a couch in the Family Room. Interview, on 02/24/2026 at 11:31 AM with the Maintenance Director, revealed the facility was not aware of the extension cord being used.The findings were verified by the Maintenance Director at the time of observation and the Inpatient Coordinator at the exit conference on 02/24/2026.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 10.2.310.2.3.2 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”

“Based on record review and interview, the facility failed to establish policies for the Patient Care Related Electrical Equipment (PCREE) in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect all PCREE, staff, and all residents. The facility had the capacity for eight (8) beds with a census of five (5) on the day of the survey. The findings include:Record review, of the PCREE testing documentation on 02/24/2026 at 2:04 PM, revealed PCREE was in use throughout the facility and there were no policies or protocols for the type of test and intervals of testing for PCREE that the facility owned. Interview, on 02/24/2026 at 2:05 PM with the Maintenance Director, revealed the facility was not aware of the PCREE requirements.The finding was verified by the Maintenance Director at the time of record review and by the Inpatient Coordinator at the exit conference on 02/24/2026. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012)3.3.137 Patient-Care-Related Electrical Equipment.Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care vicinity. 10.5.2.1 Testing Intervals.10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment.”

“Based on observation and interview, it was determined the facility failed to provide oxygen storage in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) storage room, staff, and three (3) residents. The facility had the capacity for eight (8) beds with a census of five (5) on the day of the survey. The findings include:Observation, during the building inspection tour on 02/24/2026 at 12:00 PM, revealed the Medical Gas Storage Room had three (3) freestanding oxygen H type tanks unsecured on the floor. Interview, on 02/24/2026 at 12:01 PM with the Maintenance Director, revealed the facility was not aware the H type tanks were unsecured on the floor. The findings were verified by the Maintenance Director at the time of observations and the Inpatient Coordinator at the exit conference on 02/24/2026.Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012)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. 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 11.3.2.4 Gas cylinder and cryogenic liquid container storage shall comply with 5.1.3.5.12. 11.3.2.5 Cylinder and container storage locations shall comply with 5.1.3.3.1.7 with respect to temperature limitations. 11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3.11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. (3) Cylinders shall be protected from tampering by unauthorized individuals. (4) Cylinders or cylinder valves shall not be repaired, painted, or altered. (5) Safety relief devices in valves or cylinders shall not be tampered with. (6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water. (7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. (8) Sparks and flame shall be kept away from cylinders. (9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. (10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1. (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. (12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts”