Inspection·October 17, 2023

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 10/17/23 at Life Care Center of Estero, a skilled nursing facility in Estero, Florida. Life Care Center of Estero is not in compliance with the Code of Federal Regulations (CFR) 42, Section 483.90(a)(8)(b), Physical Environment Requirements for Long-Term Care Facilities and the National Fire Protection Association (NFPA) 101 (2012 edition) Life Safety Code. Initial Plan Review: 2003 Existing NFPA 220 Construction Type: III (211) Number of beds: 155 Census: 136 The following is the description of the noncompliance.

K 325 Alcohol Based Hand Rub Dispenser (ABHR) SS=E CFR(s): NFPA 101

K 325 11/19/23 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces of aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater 11/10/2023 SUMMARY OF DEFICIENCIES 106057 10/17/2023 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD ESTERO, FL 33928 PREFIX PREFIX COMPLETION DATE

K 325 Continued From page 1 than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to install alcohol based hand rub dispensers (ABHR's) in accordance with NFPA 101. Locating ABHR's away from sources of ignition is necessary to prevent the flammable contents of the dispensers from igniting which would lead to the spread of fire, thereby endangering the occupants of the building. The findings included: On 10/17/23 at 1:10-3:30 p.m.while on tour, ABHR's were observed installed directly over light switches and receptacles in resident rooms and corridors. This was widespread in the 100 and 200 wings. Concurrent with the observations, the Administrator said that the dispensers were added during Covid and acknowledged the findings. NFPA 101 (2012 edition) 19.3.2.6

K 325 The plan of correction is submitted as required under Federal and State regulations and statutes applicable to long-term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. 1. No residents identified 2. Alcohol Based Hand Rub Dispensers (ADHR's) will be installed according to NFPA 101 (2012 Edition) 19.3.2.6 A facility audit will be completed to identify where ABHR's need to be reinstalled to be in compliance. 3. The Maintenance department will be in-serviced on the correct way to install ABHR's. 4. The Maintenance Director/designee will complete a monthly audit to ensure compliance that all ABHR's are installed according to NFPA 101 (2012 Edition) 10/17/2023 3850 WILLIAMS ROAD ESTERO, FL 33928 DEFICIENCY) COMPLETION DATE

K 325 Continued From page 2 K 325

K 902 Gas and Vacuum Piped Systems - Other SS=F CFR(s): NFPA 101 K 902 11/19/23 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be Chapter 5 (NFPA 99) This REQUIREMENT is not met as evidenced by: Based on observation and record review, the facility failed to maintain storage of compressed gasses in accordance with NFPA 101 and NFPA 99. This, in the event of a failure of the medical oxygen system would result in the system failing to operate as designed and endanger the patients dependent on medical gasses (oxygen) and compromise the smoke compartment(s) where the gasses ar stored. The findings included: On 10/17/23 at 2:28 p.m. at the oxygen storage/manifold room 246, 4 liquid oxygen and 8 "H" size compressed gas tanks were observed. The total volume of compressed and liquid oxygen was calculated to be 23,200 cubic feet. Review of the construction drawings at 3:00 p.m. revealed the following: 1) The room was designed for volumes of 19.3.2.6. The Maintenance Director/designee will track and trend the results of the audits and report the findings to the monthly 1. No residents identified. 2. Maintenance Director was able to confirm the existence of fire dampers and ceiling exhaust in storage manifold room 246. Two Liquid oxygen tanks have been removed from storage manifold room 246 to meet the storage requirements of NFPA 99.5.1.3, 9.3.7.5.3, and 55.4.1, and Chapters 6-9. 3. Maintenance department will be in-serviced on the requirements of NFPA 99.5.1.3, 9.3.7.5.3, and 55.4.1, and Chapters 6-9. 4. The Maintenance Director/designee will complete a weekly audit to ensure compliance that the oxygen storage/manifold room meets the 106057 3850 WILLIAMS ROAD ESTERO, FL 33928 COMPLETION DATE

K 902 K 902 Continued From page 3 requirements of NFPA 99 5.1.3, 9.3.7.5.3, compressed oxygen <3000 cubic feet. and 55.4.1, and Chapters 6-9. 2) The room did not have fire dampers on the The Maintenance Director/designee will HVAC supply or at the ceiling exhaust. This was track and trend the results of the audits also visually observed at 2:28 p.m.. and report the findings to the monthly 3) The room did not have the ventilation and QAPI meeting. makeup air required for systems >3000 cubic feet. NFPA 99 (2012 Edition) 5.1.3 (in its entirety), 9.3.7.5.3 (Mechanical Ventilation) NFPA 55 (2010 Edition) 4.1, and Chapters 6, 7,8, and 9 in their entirety (bulk and liquid oxygen systems) Note: Permits must be applied for and approved by AHCA's Office of Plans and Construction. Photographic evidence was obtained 10/17/2023 3850 WILLIAMS ROAD ESTERO, FL 33928 PREFIX PREFIX COMPLETION DATE

E 000 Initial Comments E 000 During the Fire & Life Safety recertification survey conducted on 10/17/23 at Life Care Center of Estero, a skilled nursing facility, Emergency Preparedness regulations were reviewed. Life Care Center of Estero is in compliance with the Code of Federal Regulations (CFR) 42, Section 483.73, Emergency Preparedness Requirement for Long-Term Care (LTC) Facilities. 35960987 10/17/2023 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD ESTERO, FL 33928 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety relicensure survey was conducted on 10/17/23 at Life Care Center of Estero, a skilled nursing facility, in Estero, Florida. This survey was completed in accordance with National Fire Protection Association (NFPA) 1 and 101 (2018 Edition) and applicable requirements of Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C) 69A-3, F.A.C. 69A-53, F.A.C. 59A-4, and Florida Statutes (F.S.) 400 Part II, and F.S. 633.0215, adopting NFPA 1 and 101 (2018 Edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. The following is the description of the deficiencies.

K 325 NFPA 101 Alcohol Based Hand Rub Dispenser SS=E (ABHR)

K 325 11/19/23 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an 11/10/23 STATE FORM 6809 U7OR21

K 325 Continued From page 1 K 325 ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Statute or Rule is not met as evidenced by: Based on observation and staff interview, the facility failed to install alcohol based hand rub dispensers (ABHR's) in accordance with NFPA 101. Locating ABHR's away from sources of ignition is necessary to prevent the flammable contents of the dispensers from igniting which would lead to the spread of fire, thereby endangering the occupants of the building. The findings included: On 10/17/23 at 1:10-3:30 p.m.while on tour, ABHR's were observed installed directly over light switches and receptacles in resident rooms and corridors. This was widespread in the 100 and 200 wings. Concurrent with the observations, the Administrator said that the dispensers were added during Covid and acknowledged the findings. NFPA 101 (2018 Edition) 19.4.3 Class III The plan of correction is submitted as required under Federal and State regulations and statutes applicable to long-term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. 1. No residents identified 2. Alcohol Based Hand Rub Dispensers (ADHR's) will be installed according to NFPA 101 (2012 Edition) 19.3.2.6.A facility audit will be completed to identify where ABHR's need to be reinstalled to be in compliance. 3. The Maintenance department will be in-serviced on the correct way to install ABHR's. 4. The Maintenance Director/designee will complete a monthly audit to ensure compliance that all ABHR's are installed according to NFPA 101 (2012 Edition) 19.3.2.6. The Maintenance Director/designee will track and trend the results of the audits and report the STATE FORM notes U7OR21 35960987 10/17/2023 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD ESTERO, FL 33928 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 325 Continued From page 2

K 325

K 902 NFPA 99 Gas and Vacuum Piped Systems - SS=F Other

K 902 findings to the monthly 11/19/23 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included. Chapter 5 (NFPA 99) This Statute or Rule is not met as evidenced by: Based on observation and record review, the facility failed to maintain storage of compressed gasses in accordance with NFPA 101 and NFPA 99. This, in the event of a failure of the medical oxygen system would result in the system failing to operate as designed and endanger the patients dependent on medical gasses (oxygen) and compromise the smoke compartment(s) where the gasses ar stored. The findings included: On 10/17/23 at 2:28 p.m. at the oxygen storage/manifold room 246, 4 liquid oxygen and 8 "H" size compressed gas tanks were observed. The total volume of compressed and liquid oxygen tanks was calculated to be 23,200 cubic feet. Review of the construction drawings at 3:00 p.m. revealed the following: 1) The room was designed for volumes of compressed oxygen <3000 cubic feet. 2) The room did not have fire dampers on the HVAC supply or at the ceiling exhaust. This was 1. No residents identified. 2. Maintenance Director was able to confirm the existence of fire dampers and ceiling exhaust in storage manifold room 246. Two Liquid oxygen tanks have been removed from storage manifold room 246 to meet the storage requirements of NFPA 99.5.1.3, 9.3.7.5.3, and 55.4.1, and Chapters 6-9. 3. Maintenance department will be in-serviced on the requirements of NFPA 99.5.1.3, 9.3.7.5.3, and 55.4.1, and Chapters 6-9. 4. The Maintenance Director/designee will complete a weekly audit to ensure compliance that the oxygen storage/manifold room meets the requirements of NFPA 99.5.1.3, 9.3.7.5.3, and 55.4.1, and Chapters 6-9. The Maintenance Director/designee will STATE FORM notes U7OR21 35960987 10/17/2023 LIFE CARE CENTER OF ESTERO 3850 WILLIAMS ROAD ESTERO, FL 33928 COMPLETE DATE

K 902 Continued From page 3 also visually observed at 2:28 p.m... 3) The room did not have the ventilation and makeup air required for systems >3000 cubic feet. NFPA 99 (2018 Edition) 5.1.3 (in its entirety), 9.3.6.5.3, 9.3.6.6 (Mechanical Ventilation) NFPA 55 (2016 Edition) 4.1, and Chapters 6, 7.8, and 9 in their entirety (bulk and liquid oxygen systems) Note: Permits must be applied for and approved by AHCA's Office of Plans and Construction. Photographic evidence was obtained Class III K 902 track and trend the results of the audits and report the findings to the monthly QAPI meeting.