Inspection·November 29, 2023

E 000 Initial Comments E 000 During the recertification survey conducted on November 29, 2023 at Oak Hammock at The University of Florida Inc., a nursing home, Emergency Preparedness Plan was reviewed. Oak Hammock at The University of Florida Inc. 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 November 29, 2023 at Oak Hammock at The University of Florida, Inc., a nursing home in Gainesville, Florida. The facility is not in compliance with 42 CFR 483.90(a), and National Fire Protection Association (NFPA) 101 (2012 Edition), NFPA 99 (2012 Edition) requirements for nursing homes. Initial Plan Review: 2004 New or Existing: Existing NFPA 220 Construction Type: II (111) Number of beds: 73 Census: 66 The following is a description of the deficiencies found at the time of the visit.

K 923 Gas Equipment - Cylinder and Container Storage SS=D CFR(s): NFPA 101 K 923 12/26/23 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 106066 11/29/2023 2600 SW 53RD LN OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

K 923 Continued From page 1 5.1.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) THIS REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the signage on oxygen storage rooms. The findings include:

K 923

K000 Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement 106066 11/29/2023 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

K 923 Continued From page 2

K 923 During the facility tour on 11/29/2023 from 1:00 PM - 3:45 PM with the Maintenance Director and Assistant Maintenance Director, the facility did not have the signage reading "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING" on the 3 oxygen storage rooms. During an interview on 11/29/2023 at 2:00 PM with the Maintenance Director and Assistant Maintenance Director, they concurred with the observation and confirmed the findings. NFPA 99 (2012 Edition) 11.3.4, 11.3.4.1, 11.3.4.2 These findings were reviewed with the Maintenance Director, Assistant Maintenance Director, and the Administrator during the exit conference on 11/29/2023 at 4:00 PM. of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. This provider respectfully requests that this plan of correction be considered the letter of credible allegation of compliance and requests a desk review in lieu of a post-survey review.

K923 IMMEDIATE CORRECTIVE ACTION 1. Temporary vinyl signage, visible from 5 feet, was installed reading CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING on the 3 oxygen storage rooms. Permanent signage upon arrival to replace temporary signage was ordered. IDENTIFICATION OF RESIDENTS 1. The facility has determined that all residents have the potential of being affected. SYSTEMATIC CHANGES 1. Permanent signage, visible from 5 feet, will be installed by the Maintenance Department on each of the 3 oxygen storage rooms upon arrival. Temporary vinyl signage will be removed and discarded. 2. Date of completion: December 26, 2023 MONITORING 1. Maintenance Director, or designee, will perform monthly inspection x 3 form months, then quarterly x 2 to ensure signage is in place and in good condition. 106066 11/29/2023 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

K 923 Continued From page 3

K 923 2. Maintenance Director, or designee, will report and discuss finding of audits at the QAPI committee monthly x 90 days for input on the need to increase, decrease, or discontinue the auditing. 35961003 11/29/2023 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA IN 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety re-licensure survey was conducted on November 29, 2023 at Oak Hammock at The University of Florida, Inc., a nursing home in Gainesville, Florida, 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 National Fire Protection Association (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. Initial Plan Review: 2004 New or Existing: Existing NFPA 220 Construction Type: II (111) Square Footage: 41,175sf Fully Sprinkled: Yes Generator: 1000kW Number of beds: 73 Census: 66 The following is a description of the deficiencies found at the time of the visit.

K 923 NFPA 99 Gas Equipment - Cylinder and SS-D Container Storag

K 923 12/26/23 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but Storage locations are outdoors in an enclosure or (X8) DATE 12/28/23 STATE FORM 6809 LFJH21 35961003 11/29/2023 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA IN 2660 SW 53RD LN GAINESVILLE, FL 32608

K 923 Continued From page 1 K 923 within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording of a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Statute or Rule is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the signage on oxygen storage rooms. The findings include: During the facility tour on 11/29/2023 from 1:00 PM - 3:45 PM with the Maintenance Director and Assistant Maintenance Director, the facility did not 35961003 11/29/2023 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA IN 2660 SW 53RD LN GAINESVILLE, FL 32608

K 923 Continued From page 2 have the signage reading "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING" on the 3 oxygen storage rooms. During an interview on 11/29/2023 at 2:00 PM with the Maintenance Director and Assistant Maintenance Director, they concurred with the observation and confirmed the findings. NFPA 99 (2018 Edition) 11.3.10, 11.3.10.1, 11.3.10.2 These findings were reviewed with the Maintenance Director, Assistant Maintenance Director, and the Administrator during the exit conference on 11/29/2023 at 4:00 PM. Class III K 923 requests that this plan of correction be considered the letter of credible allegation of compliance and requests a desk review in lieu of a post-survey review. K923 IMMEDIATE CORRECTIVE ACTION 1. Temporary vinyl signage, visible from 5 feet, was installed reading CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING on the 3 oxygen storage rooms. Permanent signage was ordered to replace temporary signage upon arrival. IDENTIFICATION OF RESIDENTS 1. The facility has determined that all residents have the potential of being affected. SYSTEMATIC CHANGES 1. Permanent signage, visible from 5 feet, will be installed by the Maintenance Department on each of the 3 oxygen storage rooms upon arrival. Temporary vinyl signage will be removed and discarded. 2. Date of completion: December 26, 2023 MONITORING 1. Maintenance Director, or designee, will perform monthly inspection x 3 months, then quarterly x 2 to ensure signage is in place and in good condition. 2. Maintenance Director, or designee, will report and discuss finding of audits at the QAPI committee monthly x 90 days for input on the need to increase, decrease, or discontinue the auditing. COMPLETED 11/29/2023 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX PREFIX COMPLETE DATE