The Sanctuary at the Woodlands

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 47295 Based on observations and interviews with staff during a tour of the hospital by Life Safety Code, it was determined the hospital was not constructed, arranged, and maintained to ensure patient safety. This had the potential to negatively affect all patients, staff, and visitors of this hospital. Findings include: Refer to tags: K-0324, K-0345, K-0353, K-0712, and K-0741.”

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 47295 Based on review of medical records (MR), policies, Bylaws, observations, and staff interviews, it was determined the Governing Body failed to ensure medical staff requirements were met. This had the potential to negatively affect all patients served by this facility. Findings include: Woodland PH Operations d/ba (doing business as) The Sanctuary at the Woodlands Medical Staff Bylaws ...3.3 Basic Responsibilities of Staff Membership... 3.3(f) Adequately prepare and complete in a timely fashion the medical and other required records for all patients he/she admits or, in any way provides care to, in the Hospital; 3.3(g) Adequately enter all orders for treatment within the timeframe required by the applicable Medical Staff Rules, Regulations... 4.2 (d) Failure Failure to carry out the responsibilities or meet the qualifications as enumerated shall be grounds for corrective action, including, but not limited to, termination of staff membership... Policy: HIPAA and Electronic Health Records Effective: 11/2023 Revised: 11/2024 ...This policy outlines the principles and procedures that govern the handling, dissemination, and protections of patient electronic and paper medical records. Procedure: ...4. Dissemination of Knowledge and information: Regular audits and assessments should be conducted to ensure compliance ...and best practices. ...8. Timeliness of Record Completion: The clinical record should be completed within 30 calendar days. Review of the MR department revealed 154 outstanding medical records dated June 2024 through October 2024 requiring physician and staff signatures. An interview was conducted on 10/10/24 at 10:24 AM with Employee Identifier # 3, Director of Medical Records, who confirmed medical records were not being signed within 30 days per policy.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49894 Based on observations, review of facility policy, and staff interviews, it was determined the facility failed to provide a safe environment for patients. These unsafe practices had the potential to negatively affect all patients served by the facility. Findings include: Facility Policy: Assessment for Suicidality and Implementing Safety Planning Policy Number: Not listed Effective Date: 4/23 ...The risk assessment, in general will also assess for protective factors, indicators that decrease the patient’s risk for suicide. ...Modified Environment and/or modified equipment. Perform a risk assessment of the environment. Ensure objects that pose a risk for self harm are removed from the patient’s location. Keep patients away from anchor points for hanging and material that can be used for self-injury/ligature. ...The safety plan initiated ...shall include, but not limited to the following: ...Restriction of access to lethal means. A tour of the facility was conducted on 10/8/22 from 10:20 AM to 11:30 AM with Employee Identifier (EI) # 1, Director of Nursing (DON). A tour of the Geriatric-Psychiatric Unit revealed the following patient safety issues: Room 305 Bed A and B: Air mattress pumps had 15 foot electrical cords not secured to the bed. Room 307 Bed A and B: Air mattress pumps had 15 foot electrical cords not secured to the bed. Room 308: An oxygen concentrator had a ten foot electrical cord. EI # 1 confirmed on 10/8/24 at 10:54 AM the oxygen concentrator electrical cord was a ligature risk and the oxygen concentrator should not be unattended in the patient room. EI # 1 also confirmed the electrical cord to the air mattress pumps should have been attached to the bottom of the beds and not accessible to patients. Ten out of ten patient rooms, including rooms 301, 302, 303, 304, 305, 306, 307, 308, 309, and 310, had bathroom door hinges that were not piano hinge (continuous hinge) style, which is a ligature risk. A tour of the Adult-Psych unit revealed the following patient safety issues: Eleven out of eleven patient rooms, including 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, and 211, had bathroom doors that were not piano hinge style, which is a ligature risk. An interview was conducted on 10/10/24 at 5:30 PM with EI # 1, who confirmed the hinges on the bathroom doors in the patient rooms were not ligature resistant per the facility policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 47295 Based on medical record (MR) reviews, facility policy, and staff interview, it was determined the facility failed to document a written modification to the patient’s Multidisciplinary Treatment Plan (MDTP) with the use of restraints. This deficient practice affected one of two MRs reviewed of restrained patients including Patient Identifier (PI) # 6, and had the potential to negatively affect all patients restrained in the facility. Findings include: Restraint/Seclusion Order and Progress Notes Form # 14016 Date reviewed 9/1/21 ...Review of plan for prevention, reduction, management of aggressive behavior/restraint: Treatment plan must be reviewed and revised, if necessary, to include step by step interventions from least restrictive to most restrictive... 1. PI # 6 was admitted on 5/15/24 with diagnoses including Schizophrenia, Bipolar Disorder, and Anxiety Disorder. Review of the MDTP dated 5/15/24 revealed plans including, no audiovisual hallucinations (AVH) or paranoia behaviors 48 hours prior to discharge, no worsening anxiety level within 48 hour of discharge, decreased AVH, paranoia, agitation, and anxiety by discharge, and will not exhibit any manic or depressive behaviors or delusional thoughts 48 hours prior to discharge. Review of the Physician’s Orders dated 5/30/24 at 8:40 PM revealed a telephone order by a Physician’s Assistant (PA) for a manual hold for a maximum time of 10 minutes. Review of the Progress Note dated 5/30/24 at 8:40 PM revealed the nurse documented PI # 6 was yelling at staff and attempting to bite and hit staff and orders were given for a manual, therapeutic hold. Further review of the MDTP revealed updated target dates but no new interventions or goals were added after the use of a manual hold on 5/30/24. An interview was conducted on 10/10/24 at 5:55 PM with Employee Identifier # 1, Director of Nursing, who confirmed there were no new interventions or goals added to the MDTP following the use of restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. This Standard is not met as evidenced by: 47295 Based on medical record (MR) review, facility policy, and interviews with staff, it was determined the facility failed to notify the attending physician of the use of restraints in one of two MRs reviewed with restraint usage. This had the potential to negatively affect all patients placed in restraints and did affect Patient Identifier (PI) # 6. Findings include: Facility Policy: Seclusion & Restraint Policy Number: 11007 Revised: 11/1/2023 Policy: The Sanctuary at the Woodlands recognizes the use of seclusion and/or restraint poses risk to the physical safety and psychological well-being of the patient and the staff... Purpose: To provide guidelines for decision making and implementing the therapeutic use of seclusion and restraints for individual patients... Immediate Reporting to Staff/Committees: Attending Psychiatrist or on call Psychiatrist, as soon as possible, but no later than 15 minutes following initiation... PI # 6 was admitted on 5/15/24 with diagnoses including Schizophrenia, Bipolar Disorder, and Anxiety Disorder. Review of the Restraint/Seclusion Order and Progress Note (form # 14016), revealed a Physician’s Assistant (PA) gave a telephone order to Employee Identifier (EI) # 6, Registered Nurse, on 5/30/24 at 8:40 PM for a manual hold restraint for no longer than ten minutes. There is no documentation of notification of the attending or on call psychiatrist within 15 minutes following restraint initiation. There is no physician signature on the order for the restraint, which states, “must be signed within 24 hours.” An interview was conducted on 10/10/24 at 5:55 PM with EI # 1, Director of Nursing, who confirmed the facility failed to ensure the psychiatrist was notified within 15 minutes following the initiation of restraints and the physician failed to sign the order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 47295 Based on medical record (MR) review and staff interview, it was determined the facility failed to notify the physician as soon as possible (ASAP) after the one hour face-to-face evaluation was performed by a registered nurse (RN) in one of two MRs reviewed with restraint usage including patient identifier (PI) # 6. This had the potential to negatively affect all patients in the facility with restraints. Findings include: Review of the Restraint/Seclusion Order and Progress Notes (form # 14016) revealed a face-to-face evaluation completed on 5/30/24 at 9:45 PM by Employee Identifier (EI) # 6, RN. There was no documentation the physician was notified ASAP after the RN performed the face-to-face evaluation. An interview was conducted on 10/10/24 with EI # 1, Director of Nursing, who confirmed the facility failed to notify the physician ASAP after a face-to-face evaluation was completed by the RN.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 41623 Based on review of medical records (MR), Potter & Perry Fundamentals of Nursing, and interviews with staff, it was determined the facility failed to ensure: 1. The physician was notified of wounds. 2. Wounds were assessed and documented to include measurement and a description of the wound. 3. Preventive measures for prevention of pressure ulcers were followed, including turning every two hours. 4. Physician orders were obtained for wound care provided. These deficient practices affected three of four MRs reviewed of patients with wounds including Patient Identifier (PI) # 4, PI # 12, and PI # 2, and had the potential to affect all patients admitted to this facility. Findings include: Potter & Perry Fundamentals of Nursing Fifth Edition Copyright 2001 ...Chapter 47: Skin Integrity and Wound Care... Management of Pressure Ulcers. ...When treating a pressure ulcer, the wound should be reassessed for location, stage, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and epithelialization... Pressure ulcers should be reassessed at least daily... 1. PI # 4 was admitted on 4/8/24 with diagnoses including Major Neurocognitive Disorder and Major Depressive Disorder. Review of the Body Audit dated 4/8/24 revealed the staff documented the presence of a small open area to the sacral area with a bandage in place. There was no documentation of assessments of the wound to include measurements, no documentation the physician was notified of the wound and no documentation of a physician’s order for care of the wound. Review of the Braden Assessment Interventions dated 4/8/24 revealed instructions to turn and reposition every two hours. Review of the Interdisciplinary Treatment Plan dated 4/8/24 revealed no identification of problems with skin integrity and no plans to prevent pressure ulcers. Review of the Daily Progress Note dated 4/9/24 revealed the Certified Registered Nurse Practitioner (CRNP) documented PI # 4 had sacral redness and a sacral pressure ulcer (PU). There was no documentation of an initial physician’s order for care of the PU. Review of the Physician’s Order Sheet dated 4/13/24 revealed orders to clean sacrum with wound cleanser, pat dry, apply barrier prep to periwound, apply medihoney to open area, cover with foam dressing daily. Review of the Nurses Notes and Care Attendant Progress Notes from 4/8/24 to 4/19/24 revealed no documentation PI # 4 was turned every two hours. Further review of the Nurses Notes from 4/9/24 to 4/12/24 revealed no documentation the wound was assessed and no documentation of wound care. Review of the Nurses Note dated 4/13/24 revealed the nurse documented PI # 4 had a discoloration to the sacrum with a small open area, 1.0 centimeter (cm) by 1.0 cm in size, there was no documentation of the depth of the wound. Review of the Nurses Note dated 4/16/24 revealed the nurse documented PI # 4 had a Stage three ulceration measuring 4.0 cm in circumference with a depth of 1.5 cm and beefy redness to the wound bed with rolled edges. An interview was conducted on 10/10/24 at 5:40 PM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the facility failed to ensure the physician was notified of wounds, preventive measures were followed for prevention of pressure ulcers, wound care was provided as ordered, and wounds were assessed per accepted standards of practice. 2. PI # 12 was admitted on 3/31/24 with a diagnosis of Major Depressive Disorder. Review of the Nursing Admission Assessment and Skin-Body Audit dated 3/31/24 revealed the nurse documented PI # 12 had blisters to both feet and discoloration to the right pinky toe. Review of the Nurses Note dated 4/5/24 revealed the nurse documented he/she noted a popped blister on the left foot. The wound was dressed with antibiotic ointment and band-aid applied. There was no documentation the physician was notified of the wound and no documentation of physician’s orders for the wound care that was provided. An interview was conducted on 10/10/24 at 5:30 PM with EI # 1, who confirmed the staff failed to notify the physician of the new wound and failed to obtain a physician’s order for the wound care provided. 3. PI # 2 was admitted on 3/15/24 with a diagnosis of Dementia, Unspecified with Agitation. Review of the Skin-Body Audit Record dated 3/15/24 revealed the nurse documented PI # 2 had thick toenails. Review of the Skin-Body Audit Record dated 3/21/24 revealed the nurse documented PI # 2 had discoloration to the toes of both feet. Review of the Skin-Body Audit Record dated 3/26/24 revealed the nurse documented PI # 2 had discoloration of the right great toe. Review of the Nurses Note dated 4/11/24 revealed the nurse documented “pt. (patient) right great toe has noted discoloration around nail and top of toe, left great toe is also starting to turn colors...” There was no documentation the physician was notified of the discoloration of the toe. PI # 2 was discharged per family request on 4/13/24 stating they were taking PI # 2 to the hospital. Review of Hospital B, receiving hospital, Emergency Department Physician Note dated 4/13/24 revealed PI # 2 had an ulceration/necrotic appearing 1.5 cm x 1.5 cm ulcer to the tip of right toe. PI # 2 was admitted to Hospital B and discharged to home on 4/19/24. An interview was conducted on 10/10/24 at 5:35 PM with EI # 1, who confirmed there was no documentation the physician was notified of the discoloration of the toe and there was no documentation of care or treatment of the toe.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 41623 Based on medical record (MR) reviews, facility policy and procedure, and interviews, it was determined the facility failed to ensure the physician signed all orders and treatment plans. This deficient practice affected two of 12 MRs reviewed including Patient Identifier (PI) # 2, and PI # 5, and had the potential to negatively affect all patients admitted to this facility. Findings include: Facility Policy: Physician’s Order - Noting Policy Number: ADM 6014 Revised: 12/01/2023 ...Procedure: 1. All physicians and CRNPs (Certified Registered Nurse Practitioner) will include the following on all orders: a. Date and time of order... f. Prescriber’s signature... 6. If the order is a verbal or telephone order, the RN/LPN (Registered Nurse/Licensed Practical Nurse) receiving the order will flag the signature line on the order...to alert the physician to sign on their next patient visit. The binder must be shown daily to the attending physician ... so the physician can counter sign any .... orders received on patients within the past 48 hours... 1. PI # 2 was admitted on 3/15/24 with a diagnosis of Dementia, Unspecified, with Agitation. Review of the Geriatric Admission Orders dated 3/15/24 revealed a verbal order from EI # 2, physician, was signed by the RN only. There was no physician signature. Review of the Home Medication Reconciliation & Physician Order dated 3/15/24 revealed a verbal order from EI # 2 was signed by the RN for medications including Alphagan Ophthalmic drops, Buspiron, Carvedilol, Cosopt Ophthalmic drops, Cymbalta, and Hydroxyzine. There was no documentation the physician signed the verbal orders. An interview was conducted on 10/10/24 at 5:35 PM with EI # 1, Director of Nursing (DON), who confirmed the admission orders nor the medication verbal orders were signed by the physician per facility policy. 49603 3. PI # 5 was admitted on 7/31/24 with diagnoses including Verbal Aggression and Recurrent Major Depressive Disorder, Severe with Psychosis. Review of the physician’s orders dated 8/15/24, 8/25/24, 8/28/24, 8/29/24, and 9/3/24 revealed no signature by the physician. An interview was conducted on 10/10/24 at 5:17 PM with EI # 1, who confirmed the orders should have been signed by the physician.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 49603 Based on a tour of the medical records (MR) department, policy and procedure, and interviews, it was determined the hospital failed to ensure physician orders were signed and dated per policy. Findings Include: Policy: HIPAA and Electronic Health Records Effective: 11/2023 Revised: 11/2024 ...This policy outlines the principles and procedures that govern the handling, dissemination, and protections of patient electronic and paper medical records. Procedure: ...4. Dissemination of Knowledge and information: Regular audits and assessments should be conducted to ensure compliance ...and best practices. ...8. Timeliness of Record Completion: The clinical record should be completed within 30 calendar days. Review of the MR department revealed 154 outstanding medical records dated June 2024 through October 2024 requiring physician signatures. An interview was conducted on 10/10/24 at 10:24 AM with Employee Identifier (EI) # 3, Director of Medical Records, who confirmed medical records were not being signed within 30 days per policy.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 41623 Based on review of medical records (MR), facility policy, and interviews, it was determined the facility failed to initiate a Treatment Plan for each patient and failed to ensure the Treatment Plan was a collaborative effort developed by an interdisciplinary team of mental health professionals.. This deficient practice affected four of twelve MRs reviewed including Patient Identifier (PI) # 12, PI # 6, and PI # 3, and PI # 5, and had the potential to affect all patients admitted to this facility. Findings include: Facility Policy: Treatment Plan Policy Number: V04 Revised: 4/2023 Purpose: Each patient receives care from an interdisciplinary team of mental health professionals. Members of this team include...psychiatrist/psychiatric provider, master prepared social worker, registered nurse... Policy: ...a. All patients admitted to the Sanctuary at the Woodlands Psychiatric Hospital should receive individualized treatment plans based on their specific needs and diagnosis. b. Treatment plans should be developed collaboratively by the patient’s treatment team... c. Treatment plans should be reviewed and updated regularly to ensure they remain relevant and effective... 3. Master Treatment Plan: a. A master treatment plan should be developed for each patient, outlining the overall goals, objectives, and strategies for their treatment... d. This plan should be initiated upon admission and completed within 72 hours of admission... 1. PI # 12 was admitted on 3/31/24 with diagnoses including General Anxiety Disorder, Major Depressive Disorder, and Moderate/Mild Neurocognitive Disorder. Review of the MR revealed no documentation a Master Treatment Plan was developed within 72 hours per facility policy. An interview was conducted on 10/10/24 at 5:30 PM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the facility failed to develop a Treatment Plan per facility policy. 47295 2. PI # 6 was admitted on 5/15/24 with diagnoses including Schizophrenia, Anxiety Disorder, and Bipolar Disorder. Review of the MR revealed a Master Treatment Plan dated 5/15/24 with a Certified Registered Nurse Practitioner’s (CRNP) signature. There was no documentation the treatment plan was developed by the interdisciplinary team per policy. An interview was conducted on 10/10/24 at 5:55 PM with EI # 1, who confirmed the facility failed to develop a collaborative treatment plan per policy. 49603 3. PI # 3 was admitted on 8/21/24 with diagnoses including Vascular Dementia, Unspecified Severity with Agitation, Seizures, and Depression. Review of the MR revealed no documentation a treatment plan was developed. An interview was conducted on 10/10/24 at 5:17 PM with EI # 1, who confirmed the facility failed to develop a treatment plan per policy. 4. PI # 5 was admitted on 7/31/24 with diagnoses including Verbal Aggression and Recurrent Major Depressive Disorder, Severe with Psychosis. Review of the MR revealed a Multidisciplinary Treatment Plan dated 7/31/24 and a Interdisciplinary Master Treatment Plan dated 8/1/24. There was no documentation the treatment plan was devloped by the interdisciplinary team, per policy. An interview was conducted on 10/10/24 at 5:17 PM with EI # 1, who confirmed the facility failed to develop a collaborative treatment plan per policy.”

“. K3 Building: 0101 K6 Plan Approval: 05/27/2010 K7 Survey Under: 2012 Existing (facility was a regular hospital prior to this) K8 HOSP Generator: One Diesel, Blue Star JD 300-02, 300kw (installed 02/2024) FACP: Simplex 4100 (installed 1975) Locks: Full time magnetic Smoke Detection: Corridor Beds: 40 Census: 29 Type of Structure: 2010 single story unprotected noncombustible, Type II(000). The facility has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 42853 . Based on review of documentation, the facility failed to maintain the kitchen hood per the requirements of: 2012 NFPA 101, 19.3.2.5.1, and 9.2.3 2011 NFPA 96, 11.4, Table 11.4, and 11.6 This deficiency affects the kitchen hood. Findings include: During a tour of the facility, the facility failed to provide documentation of a kitchen hood cleaning being conducted for January 2024. The facility did provide documentation of kitchen hood cleaning on 07/09/2024. A member of the maintenance staff was present when this deficiency was identified .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to provide a fire alarm cellular dialer per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, 26.6.2.2, 26.6.3.1.4.1, and 10.12.1 This deficiency affects the comunication of the fire alarm system. Findings include: During a tour of the facility, the surveyor observed that the newly installed cellular dialer was not the required UL 864 model for health care. The installed dialer model was UL S2576. This cellular dialer could not be tested, per the fire alarm company. A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 42853 . Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8 2011 NFPA 25, 14.2.1 This deficiency affects the automatic sprinkler system. Findings include: During the review of the documentation, the facility failed to provide documentation of conducting the automatic sprinkler internal pipe inspection within the past 5 years. A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 42853 . Based on review of documentation, the facility failed to conduct fire drills per the requirements of: 2012 NFPA 101, 19.7.1.6, 4.7.2, 4.7.4, and 4.7.6 This deficiency affects 2 of 12 fire drills. Findings include: During a tour of the facility, the facility failed to provide the documentation of fire drills being conducted for the 2023’s fourth quarter for the second and third shifts (October and November of 2023). A member of the maintenance staff was present when this deficiency was identified. .”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain the area where smoking is permitted per the requirements of: 2012 NFPA 101, 19.7.4 (6) This deficiency affects 1 of 2 smoking areas. Findings include: During a tour of the facility, the surveyor observed the smoking area located outside of the Administration Hall’s rear egress door was missing the metal container with a self-closing lid. A member of the maintenance staff was present when this deficiency was identified.”