Inspection·January 9, 2025

E 000 Initial Comments

E 000 During the Fire & Life Safety recertification survey conducted on 1/09/25 at Life Care Center of Palm Bay, Emergency Preparedness was reviewed. Life Care Center of Palm Bay is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long-Term Care Facilities.

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 1/09/25 at Life Care Center of Palm Bay, a Long-Term Care facility in Palm Bay, Florida. Life Care Center of Palm Bay is not in compliance with 42 CFR 483.90 (a), and National Fire Protection Association (NFPA) 101 (2012 edition), NFPA 99 (2012), requirements for Long-Term Care facilities. Initial Plan Review: 2004 Existing NFPA 220 Construction Type: V(III) Number of beds: 140 Census: The following is a description of the noncompliance:

K 345 Fire Alarm System - Testing and Maintenance SS=E CFR(s): NFPA 101

K 345 2/9/25 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 01/17/2025 106060 01/09/2025 LIFE CARE CENTER OF PALM BAY 175 VILLA NUEVA AVE PALM BAY, FL 32907 ID PREFIX TAG PREFIX TAG (EACH SUMMARY MUST BE PRECEDED BY FULL DEFICIENCY) COMPLETION DATE

K 345 Continued From page 1 available.

K 345 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This REQUIREMENT is not met as evidenced by: Based on record review, and an interview with the Maintenance Director, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This failure resulted in possible endangerment to the residents, staff, and other building occupants. 1) Maintenance Director located report after life safety survey and is provided as an attachment to plan of correction to area office. Testing was completed on March 6, 2024. Findings Include: 2) Maintenance Director has received education related to improved organization of inspection binder to improve ease of use and retrieval of documents. During a record review with the Maintenance Director on 1/09/25 at 10:45 AM, he failed to provide evidence that the duct detectors' annual air flow testing had been conducted. An interview was conducted with the Maintenance Director at that time and he concurred and acknowledged the findings. 3) This task is in the TELS system and will be scheduled annually with provider during annual fire alarm testing. NFPA 101(2012 Edition) 19.3.4.4, 9.6.5.1 NFPA 72 (2010 Edition) 14.4.5.3.2 4) Maintenance Director will report to QAPl committee monthly the completion of all inspections as needed.

K 921 2/9/25

K 921 SS=D CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenan Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance 106060 01/09/2025 LIFE CARE CENTER OF PALM BAY 175 VILLA NUEVA AVE PALM BAY, FL 32907 ID PREFIX TAG PREFIX TAG COMPLETION DATE DEFICIENCY)

K 921 Continued From page 2

K 921 with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This REQUIREMENT is not met as evidenced by: 1) Electrical equipment testing was completed on 12/26/2024 which is the date inspection was due to be competed. Based on observation, interview, and record review, the facility failed to maintain the annual 2) Facility received completed inspection electrical testing of fixed and portable medical report on 1/16/2025. equipment. This failure resulted in possible endangerment to the residents, staff, and other building occupants. 3) Facility will request vendor provide Findings include: inspection report in a timely manner. During record review on 1/09/25 at 10:30 AM with Maintenance Director will inform the Maintenance Director a request for the annual administrator if facility does not receive biomedical testing was made. The Maintenance documentation from a vendor timely. Director was not able to provide the biomedical Administrator will follow up as appropriate. testing documentation. The date the biomedical 4) Maintenance Director will report the testing was last performed (on 12/26/24) was status of all required inspections to the identified from a sticker observed on equipment QAPl committee monthly in the rehabilitation room, which put the testing date out of compliance. An interview was 01/09/2025 LIFE CARE CENTER OF PALM BAY 175 VILLA NUEVA AVE PALM BAY, FL 32907 PREFIX COMPLETION DATE

K 921 Continued From page 3 conducted at that time with the Maintenance Director, and he concurred and acknowledged the findings. Per NFPA 99 (2012 Edition) 10.3, 10.5.2.1 K 921 DEPARTMENT OF DEFICIENCIES 35960988 01/09/2025 LIFE CARE CENTER OF PALM BAY 175 VILLA NUEVA AVE PALM BAY, FL 32907 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 000 INITIAL COMMENTS

K 000 A unannounced Fire & Life Safety relicensure survey was conducted on 1/09/25 at Life Care Center of Palm Bay, a nursing home in Palm Bay, Florida in accordance with National Fire Protection Association (NFPA) 1 and 101 (2021 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 National Fire Protection Association (NFPA) 1 and 101 (2021 edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. The following is a description of the deficiencies, found at the time of the visit.

K 345 NFPA 101 Fire Alarm System - Testing and SS=E Maintenance

K 345 2/9/25 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. 9.6.5, 9.6.7, 9.6.8, and NFPA 70, NFPA 72 This Statute or Rule is not met as evidenced by: Based on record review, and an interview with the Maintenance Director, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This failure resulted in possible endangerment to the residents, staff, and other building occupants. 1) Maintenance Director located report after life safety survey is provided as an attachment to plan of correction to area office. Testing was completed on March 6, 2024. 01/17/25 STATE FORM 8899 8RV721 01/09/2025 LIFE CARE CENTER OF PALM BAY 175 VILLA NUEVA AVE PALM BAY, FL 32907 DEFICIENCY) DATE

K 345 Continued From page 1 K 345 Findings Include: During a record review with the Maintenance Director on 1/09/25 at 10:45 AM, he failed to provide evidence that the duct detectors' annual air flow testing had been conducted. An interview was conducted with the Maintenance Director at that time and he concurred and acknowledged the findings. NFPA 101(2021 Edition) 19.3.4.4, 9.6.5.1 NFPA 72 (2017 Edition) 14.4.5.3.2 CLASS III

K 921 NFPA 99 Electrical Equipment - Testing and SS=D Maintenanc K 921 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed 2/9/25 STATE FORM 699 8RV721 01/09/2025 LIFE CARE CENTER OF PALM BAY 175 VILLA NUEVA AVE PALM BAY, FL 32907 PREFIX COMPLETE DATE

K 921 Continued From page 2 K 921 operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.12, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 (NFPA 99) This Statute or Rule is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain the annual electrical testing of fixed and portable medical equipment. This failure resulted in possible endangerment to the residents, staff, and other building occupants. Findings include: During record review on 1/09/25 at 10:30 AM, with the Maintenance Director a request for the annual biomedical testing was made. The Maintenance Director was not able to provide the biomedical testing documentation. The date the biomedical testing was last performed (on 12/26/24) was identified from a sticker observed on equipment in the rehabilitation room, which put the testing date out of compliance. An interview was conducted at that time with the Maintenance Director, and he concurred and acknowledged the findings. Per NFPA 99 (2021 Edition) 10.3, 10.5.2.1 CLASS III 1) Electrical equipment testing was completed on 12/26/2024 which is the date inspection was due to be completed. 2) Facility received completed inspection report on 1/16/2025. 3) Facility will request vendor provide inspection report in a timely manner. Maintenance Director will inform administrator if facility does not receive documentation from a vendor timely. Administrator will follow up as appropriate. 4) Maintenance Director will report the status of all required inspections to the QAPI committee monthly. STATE FORM esss 8RV721