Freedom Plaza Care Center

Based on review of the Emergency Plan (EP), facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policy and procedure at alternative care sites may cause harm to the residents during an emergency.

Findings include:

During document review on May 08, 2024, it was revealed the facility's Emergency Plan related to the section which addresses policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.


Facility managment confirmed during document review that the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on observation the facility failed to provide adequate fire protection and separation between an assistated Living Centerand the nursing home. Failing to have proper rated systems in the facility could harm patients and staff during a fire emergency.

NFPA 101 2012 Edition. 19.1.3 Multiple Occupancies. 19.1.3.3 Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: 1. They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation. 2. They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.3. For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7

Findings include:

Observations made while on tour on May 08, 2024, revealed the following:

1) No firewall separation between the Care Center and Assisted Living.
2) The firewall at Front Ave is not complete in the therapy room as well as the outpatient therapy. The fire wall did not extend to the deck above.

During the exit conference on May 08, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1.

Findings include:

Observations made while on tour on May 08, 2024, revealed the following:

There was not a fire extenguish installed within 50 feet of the generator.

During the exit conference on May 08, 2024, the above finding were again acknowledged by the management team.

Based on observation it was determined the facility failed to fill penetrations in four (4) of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.
Findings include:

During a facility tour conducted on May 08, 2024, revealed the facility failed to maintain the smoke barriers in the fire/ smoke barrier in the following areas:

1) No sealing on the firewall between the activity's office and the beauty salon.
2) The firewall patch is not properly sealed in the 100 hall.
3) The fire-rated wall in the water heater room has holes.
4) No tape texturing on the firewall leading to the kitchen.

During the exit conference on May 08, 2024, the above listed findings were again acknowledged by the management team.

Based on personnel file review, staff interviews, and facility document review, the facility failed to ensure that one employee's (staff #33) personnel record included documentation of fingerprint clearance.

Findings include:

Review of the personnel file for a Housekeeper (staff #33) revealed a hire date November 1, 2022. Further review of the personnel file revealed no evidence of fingerprint clearance.

On January 11, 2023 at 8:59 a.m., a written request for a copy of staff #33's fingerprint clearance. The Human Resources (HR) Generalist (staff #135) stated that the individual did not have a fingerprint clearance. She annotated this on the returned request form.

An interview was conducted with the HR Generalist (staff #135) on January 11, 2023 at 12:24 p.m. Staff #135 stated that the other individual (staff #48) identified on the fingerprint clearance request was underage and was only 16 years of age. She stated that the facility employs about 10 minors who works as dietary aide. These employees do not have fingerprint clearance cards. Additionally, she stated that most if not all auxiliary staff hired after December 2021 have no fingerprint clearance. She said that this is due to the facility policy in which the previous administrator noted that only staff providing actual care in skilled nursing are the only required to have a fingerprint clearance.

A clarification regarding minors needing fingerprint clearance was discussed with the survey team on January 11, 2023 at approximately 12:45 p.m. The team coordinator reached out to the State Agency's Bureau Chief to verify the requirement. It was determined that as long as the minor is not providing direct care to the resident and was in the direct supervision of an individual with a valid fingerprint clearance then the minor does not require a fingerprint clearance.

An interview with the Dietary Manager (staff #40) was conducted on January 11, 2023 at 12:50 p.m. He stated that his underage staff work as servers/dietary aide. Staff #40 stated that these staff do not enter the residents' room. They deliver car to common areas and they do not do anything with the resident.

An interview was conducted on September 1, 2022 at 12:18 p.m. with the Director of Nursing (DON/staff #18). She stated that she had been made aware of the minors working in the facility and the current facility policy regarding fingerprint clearance. Staff #18 stated that she feels that everyone working in the facility should be fingerprinted.

Review of the facility's policy titled "Fingerprint Policy" updated December 2021 revealed the facility only required fingerprint clearance staff providing actual care in Skilled Nursing per the previous administrator.

The facility policy titled "AZ Hiring Policy" adopted April 4, 2018 stated that the company conducts background and reference checks in conformance with all applicable federal and state laws. This includes providing applicants with required notices and information regarding such background and reference checks.