Inspection·March 3, 2025

K 000 INITIAL COMMENTS K 000 An unannounced Fire & Life Safety recertification survey was conducted on 03/03/2025 at Haven of Our Lady of Peace, a nursing home in Pensacola, Florida. The facility is in compliance with Code of Federal Regulations (CFR) 42, Part 483.90, Requirement for Long Term Care Facilities: Physical Environment and National Fire Protection Association (NFPA) 101 (2012 edition) and NFPA 99 (2012) requirements for nursing homes. Initial Plan Review: 2001 Existing NFPA 220 Construction Type: II (111) Number of beds:120 Census:106 03/13/2025 03/03/2025 11705 HAVEN OF OUR LADY OF PEACE 1900 SUMMIT BOULEVARD PENSACOLA, FL 32503 DEFICIENCY)

K 000 INITIAL COMMENTS K 000 An unannounced Fire & Life Safety re-licensure survey was conducted on 03/03/2025 at Haven of Our Lady of Peace, a nursing home in Pensacola, Florida, in accordance with National Fire Protection Association (NFPA) 1 and 101 (2021 edition) regulations and all applicable requirements of the 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) standards, collectively known as the Florida Fire Prevention Code, and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. There were deficiencies found at the time of the visit.

K 300 NFPA 101 Protection - Other K 300 4/5/25 SS=D Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection 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. 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 ceiling tiles. Failure to maintain ceiling tiles within a suspended ceiling can cause a delay in fire sprinkler actuation and allow smoke to travel to other parts of the building during a fire event. The findings include: 1. The ceiling tiles in the kitchen, service hallway, room 418, center area of Trinity Court, 2nd floor hall between the elevators and Room 315, 316 and 310 were replaced with new ceiling tiles. 2. An audit of all ceiling tiles will be conduct and replaced as necessary. 3. The Administrator will train the Maintenance Director and Maintenance

K 300 Continued From page 1 K 300 During the Fire & Life Safety tour of the facility with the Director of Maintenance on 03/03/2025 between 09:00 am and 11:00 am, it was observed that ceiling tiles were damaged or painted in the following locations: 1. There were painted tiles in the kitchen. 2. There were painted tiles in the service hall. 3. Room 418 had painted tiles. 4. The Trinity Court center area had painted tiles. 5. There were painted tiles on the 2nd floor hall between the elevators. 6. Rooms 315,316, and 310 had painted tiles. An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings. Please refer to NFPA 101 (2021 edition). Class III

K1004 NFPA 101 Maintenance Personnel SS=D K1004 3/28/25 Maintenance, inspection, and testing shall be under the supervision of a responsible person who shall ensure that testing, inspecting, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction. NFPA 101 (2015) 4.6.12.5 This Statute or Rule is not met as evidenced by: Based on observation and interview, the facility failed to ensure regular inspection and maintenance of the Heating, Ventilation, and Air 1. The air filters were replaced with in all resident rooms and common areas. a. The Laundry exhaust filter system will COMPLETED 03/03/2025 HAVEN OF OUR LADY OF PEACE 1900 SUMMIT BOULEVARD PENSACOLA, FL 32503 PREFIX REGULATORY OR LSC PRECEDING INFORMATION) | ID PREFIX COMPLETE DATE

K1004 | Continued From page 2 | K1004 | | Conditioning (HVAC) system and the laundry dryer system. This condition could result in one or more systems in the residence to fail. The findings include: During the Fire & Life Safety tour of the facility with the Director of Maintenance on 02/25/2025 between 09:00 am and 11:00 am, the following concerns were observed: 1. Patient room return air vents and filters were loaded with dust. 2. The laundry dryer exhaust filter system was broken. Per NFPA 101 (2021) section 4.6.12.5, "Maintenance, inspection, and testing shall be under the supervision of a responsible person who shall ensure that testing, inspecting, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction." Class III be repaired and completed 3/28/25 2. An audit of all air filters will be conducted and replaced as necessary. a. No further action will be taken on the laundry exhaust filter system. 3. The Administrator will train the Maintenance Director and Maintenance Department on the LSC Section 4.6 and 12.5. a. Air Filter monitoring was placed on Preventative Maintenance schedule. b. Laundry Dryer exhaust filter system was placed on quarterly preventative maintenance system. 4. The Maintenance Director/Designee will conduct random audits of air filters monthly. The results of audits will be reported by the Maintenance Director to the QAPI Committee for 3 months to the QAPI committee for review and actions needed as appropriate. a. The Maintenance Director/Designee will conduct random audits of laundry dryer exhaust filter and present QAPI committee for review and actions needed as appropriate. STATE FORM eee JSS621