Inspection·May 8, 2023

K 916 | NFPA 99 Electrical Systems - Essential Electric SS=D | K 916 | | 6/5/23 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.17, 6.4.1.17.5 (NFPA 99) This Statute or Rule is not met as evidenced by: Based on observation and interview with the Maintenance Director, the facility failed to maintain the remote annunciator panel for the generator in a manner that would provide for a "Generator watch initiated. 1-hour checks immediately initiated 7 days a week / 24 hours to ensure that the generator panel is showing all the required safety indicators" AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE (X6) DATE 06/01/23 STATE FORM 6809 C8MY21 If continuation sheet 1 of 2 Agency for Health Care Administration PRINTED: 06/28/2023 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 11704 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER ROSEWOOD HEALTHCARE AND REHABILITATION CI STREET ADDRESS, CITY, STATE, ZIP CODE 3107 NORTH H STREET PENSACOLA, FL 32501 | (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) | (X6) COMPLETE DATE | |-------------------|-------------------------------------------------------------------------------------------------------------------|--------------|---------------------------------------------------------------------------------------------------------------|-------------------| | K 916 | Continued From page 1 | K 916 | | | | | visual indicator for malfunction. This could result in a generator malfunction without staff being aware, thus resulting in loss of emergency power to the facility. | | are properly functioning and are not alarming. Professional contractor Power Secure contacted and came out to investigate the appropriate annunciator panel to match the generator. | | | | The findings include: | | "Local annunciator panel checks were implemented along with generator checks to ensure staff and resident safety requirements are met. In services initiated on the generator panel 1-hour checks 7 days a week/24 hour. 100% of in-service days is completed. | | | | During the Fire & Life Safety tour of the facility with the Maintenance Director on 05/08/2023 from 10am to 12pm, the emergency generator was found to be broken, and the facility was using a rental unit of 50 Kilowatts. The facility did not connect the portable generator to the remote annunciator panel. Also, the facility does dialysis on site and the second generator (60 kilowatt) used for their cool zones does not have a remote annunciator panel. The Maintenance Director verified these findings at the times observed. | | "Power Secure has ordered and will install the appropriate annunciator for the level 1 generator. Contract was signed on 5/30/2023. Installation time expected within 20-30 days or sooner. Maintenance director and/or designer will continue to monitor progress with Power Secure and maintenance consultant. | | | | This violates NFPA 99, 6.4.1.1.17, which states, "A remote annunciator, storage battery powered, shall be provided to operate outside of the generator room in a location readily observed by operating personnel at a regular workstation (see NFPA 70, National Electrical Code, Section 700-12.) Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 6.4.1.1.17(a) and (b) occur but need not display these conditions individually." | | "The generator watch logs will be reviewed daily x3 month by Administrator, Maintenance or Designee until all repairs are completed. Any new findings will be corrected and presented to the QAPI committee for further research. monitoring/interventions needed monthly or as needed. | | AHCA Form 3020-0001 STATE FORM notes C8MY21 if continuation sheet, 2 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 06/28/2023 FORM APPROVED OMB NO. 0938-0391 LIST OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 105747 B. WING 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CENTER 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 05/08/2023 at Rosewood Healthcare & Rehabilitation Center, a nursing home in Pensacola, Florida. The facility is not in compliance with Code of Federal Regulations (CFR) 42, Part 483.90 (a), National Fire Protection Association (NFPA) 101 (2012 edition) regulations, and NFPA 99 (2012) requirements for nursing homes. The facility was found to be not in compliance at the time of this survey. Initial Plan Review: 1963 Existing NFPA 220 Construction Type: II (222) Number of beds: 160 Census: 143

K 916 Electrical Systems - Essential Electric Syste SS-D CFR(s): NFPA 101

K 916 6/5/23 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This REQUIREMENT is not as evidenced by: Based on observation and interview with the Maintenance Director, the facility failed to maintain the remote annunciator panel for the generator in a manner that would operate for a "Generator watch initiated. 1-hour checks immediately initiated 7 days a week / 24 hours to ensure that the generator panel is showing all the required safety LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 06/01/2023 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8MY21 Facility ID: 11704 If continuation sheet Page 1 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 06/28/2023 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 05/08/2023 105747 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CENTER 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID (X5) SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETION DATE

K 916 K 916 Continued From page 1 indicators are properly functioning and are visual indicator for malfunction. This could result not alarming. Professional contractor in a generator malfunction without staff being Power Secure contacted and came out to aware, thus resulting in loss of emergency power investigate the appropriate annunciator to the facility. panel to match the generator. The findings include: "Local annunciator panel checks were During the Fire & Life Safety tour of the facility implemented along with generator checks with the Maintenance Director on 05/08/2023 to ensure staff and resident safety from 10am to 12pm, the emergency generator requirements are met. In services initiated was found to be broken, and the facility was using on the generator panel 1-hour checks 7 a rental unit of 50 Kilowatts. The facility did not days a week/24 hour. 100% of in-service connect the portable generator to the remote is completed. annunciator panel. Also, the facility does dialysis on site and the second generator (60 kilowatt) "Power Secure has ordered and will install used for their cool zones does not have a remote the appropriate annunciator for the level annunciator panel. The Maintenance Director 1 generator. Contract was signed on verified these findings at the times observed. 5/30/2023. Installation time expected within 20-30 days or sooner. This violates NFPA 99, 6.4.1.1.17, which states, Maintenance director and/or designer will "A remote annunciator, storage battery powered, continue to monitor progress with Power shall be provided to operate outside of the Secure and maintenance consultant. generator room in a location readily observed by operating personnel at a regular workstation (see "The generator watch logs will be NFPA 70, National Electrical Code, Section reviewed daily x3 month by Administrator, 700-12.) Where a regular workstation will be Maintenance or Designee until all repairs unattended periodically, an audible and visual are completed. Any new findings will be derangement signal, appropriately labeled, shall corrected and presented to the QAPI be established at a continuously monitored committee for further research location. This derangement signal shall activate monitoring/interventions needed monthly when any of the conditions in 6.4.1.1.17(a) and or as needed. (b) occur but need not display these conditions individually." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CSMY21 Facility ID: 11704 If continuation sheet Page 2 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PLAN OF CORRECTION AND STATEMENT OF DEFICIENCIES PRINTED: 06/28/2023 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING __________ B. WING ________ (X3) DATE SURVEY COMPLETED 05/08/2023 105747 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CENTER 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID (X5) SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) (X6) ID PREFIX TAG (X7) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X8) COMPLETION DATE

E 000 Initial Comments E 000 During the recertification survey conducted on 05/08/2023 at Rosewood Healthcare & Rehabilitation Center, a nursing home, in Pensacola, Florida, the Emergency Preparedness Program was reviewed. Rosewood Healthcare & Rehabilitation Center does not comply with the Emergency Preparedness rule per Code of Federal Regulations (CFR) 42, Part 483.73, and Requirement for Long-Term Care Facilities.

E 015 Subsistence Needs for Staff and Patients SS=D E 015 6/5/23 $403.748(b)(1), $418.113(b)(6)(iii), $441.184(b) (1), $460.84(b)(1), $482.15(b)(1), $483.73(b)(1), $483.475(b)(1), $485.542(b)(1), $485.625(b)(1) [[b] Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed 06/01/2023 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date of survey these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:C8MY21 Facility ID: 11704 If continuation sheet Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 06/28/2023 FORM APPROVED OMB NO. 0938-0391 REPORT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ________ (X3) DATE SURVEY COMPLETED 105747 B. WING ________ 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CENTER 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

E 015 Continued From page 1 provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of substance needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This REQUIREMENT is not met as evidenced by: Based on observation, record review, and interview, the facility failed to incorporate the policy and procedures for substance needs for staff and patients into their Emergency Preparedness Program. The program did not completely incorporate provisions for maintaining temperatures in the event of the loss of the local utility. The findings include: "The facility immediately implemented an emergency preparedness plan and policy for the dialysis den area. This plan /policy includes any temperature monitoring, loss of utility services, and operation of equipment under emergency conditions. "Upon any power outage and when temps or equipment cannot be maintained, the dialysis resident identified will be relocated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:CSMY21 Facility ID: 11704 If continuation sheet Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 06/28/2023 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ (X3) DATE SURVEY COMPLETED 105747 B. WING ______ 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CENTER 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

E 015 Continued From page 2

E 015 to the designated area within the building and or evacuated to the sister facility with in house dialysis per the emergency plan. The facility could not produce documentation of their ability to maintain temperatures in the dialysis room in the event of the loss of the local utility. The facilities two generators are not connected to a remote annunciator panel. This is a violation of Code of Federal Regulations (CFR) 42, Part 483.73 (1)(a), Requirements for Long-Term Care Facilities. "Quarterly tabletop for Emergency Preparedness Plan initiated 100% of in services initiated on emergency preparedness plan, power outage temperature checks, and relocation of residents if needed, which includes contracted dialysis staff The NFPA 99 Equipment Assessment Worksheet will be implemented. "All findings will be presented to the QAPI committee for further monitoring/interventions needed monthly or as needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:CSMY21 Facility ID: 11704 If continuation sheet Page 3 of 3