Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
14E
0F
Potential for minimal harm
0A
0B
1C
February 7, 2023Standard inspection · 13 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on Resident interviews, facility staff interviews and facility documentation review, the facility staff failed to permit the Resident Council to meet without a staff member being present which had the potential to affect Residents who attend resident council.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on Resident Interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide services to maintain personal hygiene for 2 Residents (#222, and #375) in a survey sample of 73 Residents.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (R)141 out of one reviewed for advanced directives was provided written information of the right to accept or refuse medical or surgical treatment and formulate an advance directive.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure written acknowledgement of the Notice of Medicare Non Coverage for two Residents (Resident # 81 and # 123) in a survey sample of 3 Residents reviewed for Beneficiary Notices.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to provide ensure that the appropriate information regarding a transfer was communicated to the receiving health care institution or provider for one Resident (Resident # 8) in a survey sample of 73 Residents.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to provide Notice to the Ombudsman of discharge for one Resident (Resident # 8) in a survey sample of 73 Residents.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to provide the bed hold policy to the resident and resident representative for one Resident (Resident # 8) in a survey sample of 73 Residents.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure care plan measures were developed and implemented to prevent skin injury during care for one Resident (Resident #222) in a survey sample of 73 Residents.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a discharge summary was written for one Residents (# 171) in a survey sample of 73 Residents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to prevent, and treat timely, a stage 2 pressure ulcer prior to development for one Resident (Resident #222) in a survey sample of 73 residents.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on record review, resident interview, staff interview, the facility failed to ensure routine dental services were offered to one of one Resident (R)26 reviewed for dental services.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure Committee Members were present for QAPI meetings for 4 of 4 QAPI meetings.
- C
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteBased on observation, Resident interviews, staff interview, and facility documentation review, the facility staff failed to have posted the list of names, addresses and telephone number of all pertinent State agencies and advocacy groups affecting Residents on all 5 nursing units.
April 30, 2019Standard inspection · 28 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, resident interview, and facility documentation review the facility staff failed to provide a dignified dining experience in 1 of 6 dining rooms (involving multiple residents) and for two Residents (Resident #29, Resident #82) in a survey sample of 60 Residents. 1. The facility staff failed to serve meals to all residents at the same table, at the same time, in 1 of 6 dining rooms. 2. For Resident #29, the facility staff stood over resident while feeding and after feeding the resident three bites, left to go assist a different resident . 3. For Resident #82, the facility staff failed to serve meals at the same time as her table mates.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to develop comprehensive, resident-centered care plans for 6 residents (Resident #146, Resident #14, #105, #180, #49, and #192) in a sample of 60 residents. 1. For Resident #146, the facility staff failed to complete a comprehensive care plan for bathing & foley catheter care. 2. For Resident #14, the facility staff failed to complete a comprehensive care plan for contracture care. 3. For Resident #105, the facility staff identified the resident was at high risk for falls on 2/15/19 and failed to develop a comprehensive careplan to include interventions to prevent falls until 3/21/19. 4. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, facility documentation review, and clinical record review, the facility staff failed to provide adequate ADL (activities of daily living) care for four residents (Resident #146, #14, #86, and Resident #51) in the survey sample of 60 Residents. 1. For Resident #146, the facility staff failed to provide adequate fingernail and incontinence care. 2. For Resident #14, the facility staff failed to provide adequate nail care, and skin care. 3. For Resident #86, the facility staff failed to provide assistance with eating. 4. For Resident #51, the facility staff failed to provide timely assistance with ADL's (Activities of Daily Living) and in accordance with plan of care.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote3. For Resident #251, the facility failed to ensure that she was free of a malfunctioning wheelchair - related accident hazard. Resident #251 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #251's diagnoses included Anxiety Disorder, Dementia, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Gout, Heart Failure, and Age-related Nuclear Cataract - Bilateral. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/1/19 was reviewed. Resident #251 was coded as having a Brief Interview of Mental Status Score of 9, indicating moderately impaired cognition. Resident #251 was also coded as having impaired vision. In addition, she was coded as being independent in locomotion with a wheelchair. On 4/28/19 at approximately 4:00 P.M., an interview was conducted with Resident #251 at the nurse's station. [...]
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review the facility staff failed to ensure four Resident's (Resident #84, Resident #28, Resident #452, and Resident #113) received oxygen as ordered, in a survey sample of 60 Residents 1. For Resident #84, the facility staff failed to ensure that physician ordered continuous oxygen was administered in accordance with the plan of care. 2. For Resident #28, the facility staff failed to provide continuous oxygen treatment as ordered by the physician. 3. For Resident #452, the facility staff failed to ensure she received continuous oxygen therapy. 4. For Resident #113, the facility staff failed to ensure that physician ordered continuous oxygen was administered in accordance with the plan of care.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on Resident interview, staff interview, facility documentation and clinical record review the facility staff failed to ensure sufficient staff for adequate care. 1. The facility staff failed to provide sufficient staff to answer calls bells in a timely manner. 2. The facility staff failed to provide sufficient staff to feed Residents in timely manner. 3. For Resident #146, the facility failed to provide sufficient staff to maintain bathing and hygiene cleanliness.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to properly store medication and the facility staff failed to provide a separately locked, permanently affixed compartments for storage of controlled drugs in three of five medication rooms. 1. Fluticasone for Resident #81 and Humalog for Resident #170 were sitting out on top of Medication Cart #1 on the Midlothian unit unsupervised. 2. In three of five medication rooms the facility staff failed to provide a separately locked, permanently affixed compartment for storage of refrigerated controlled drugs.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations and staff interviews, the facility staff failed to assign staff with appropriate skill set to effectively carry out the functions of food and nutrition services. The facility staff assigned a dietary aide to the 3-compartment sink before he received the training and competencies to do so.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and facility documentation, the facility staff failed to follow proper sanitation practices facility-wide and failed to serve food with proper sanitation practices and at proper holding temperature in one of six dining rooms. 1. A facility staff member held a pen and the thermometer in her gloved hand simultaneously while temping the pureed eggs, the pureed sausage, and the sausage gravy. The pen hovered over the food and touched the edges of the food container at times during the temping process. 2. According to the facility's sanitizer solution log, the three compartment sink was not tested for three days in April to ensure the pots were effectively sanitized and chemical contamination was avoided. 3. The facility staff failed to perform proper hand washing prior to meal service. 4. [...]
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain accurate and readily accessible medical records for four residents (Resident #198, Resident #179, Resident #452, Resident #105) in a sample size of 60 residents. 1. For Resident #198, the social worker did not document social services notes in the clinical record but kept notes in a soft file in her office. 2. For Resident #179, the social worker did not document social services notes in the clinical record but kept notes in a soft file in her office. There are inconsistencies in the bowel and bladder status documentation and the bowel and bladder elimination record is incomplete. 3. [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, facility documentation review, and clinical record review, the facility staff failed to assess if a resident was safe to self administer medications for one Resident (Resident #149), in a survey sample of 60 Residents. For Resident #149, the facility staff failed to assess if the resident was safe to self administer prescription medications kept at the bedside.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wrote2. For Resident #251, the facility staff failed to accommodate her need for an appropriate wheelchair. Resident #251 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #251's diagnoses included Anxiety Disorder, Dementia, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Gout, Heart Failure, and Age-related Nuclear Cataract - Bilateral. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/1/19 was reviewed. Resident #251 was coded as having a Brief Interview of Mental Status Score of 9, indicating moderately impaired cognition. Resident #251 was also coded as having impaired vision. In addition, she was coded as being independent in locomotion with a wheelchair. On 4/28/19 at approximately 4:00 P.M., an interview was conducted with Resident #251 at the nurse's station. [...]
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to ensure residents' right to privacy during a Resident Group Interview. The facility Social Worker (Employee K) interrupted a private meeting and violated the residents right to privacy by walking into and throughout the meeting room uninvited.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to notify the physician and responsible party that medications were available for administration for one Resident (Resident # 128) in a survey sample of 60 residents. For Resident #128, the facility staff failed to notify the physician and responsible party of several medications that were unavailable for administration including, but not limited to: the breathing treatment medication Acetylcysteine Solution 20%, the thyroid medication- Levothyroxine 50 micrograms and the mood disorder medication, Depakote 250 milligrams.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, and staff interview the facility failed to ensure a clean comfortable homelike environment for Residents in the Memory Care Unit, and Resident's # 146, and #14 in a survey sample of 60 Residents. 1. For the memory care Unit the facility staff was checking blood pressures and administering medications during breakfast meal. 2. Resident #146's room smelled strongly of urine and the floors were coated with a sticky dirty film. 3. Resident #14's room smelled strongly of urine and the floors were coated with a sticky dirty film
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on Resident Representative interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure that appropriate information was communicated to the hospital for one Resident (Resident #105) in a survey sample of 60 Residents. For Resident #105, the facility staff failed to provide the receiving facility with a list of the resident's current medications at the time of transfer to the hospital.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to provide the bed hold policy to the resident and resident representative for one Resident (Resident #105) in a survey sample of 60 Residents. For Resident #105, the facility staff failed to provide the resident and resident representative with the bed hold policy at the time of transfer to the hospital.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on facility documentation and clinical record review the facility failed to ensure Residents had (Pre admission Screening and Resident Review) PASARR Level II screening prior for 1 Resident (#97) in a survey sample of 60 Residents. 1. For Resident #97 the facility staff failed to obtain the required Level II screening done based on results of Level I. The Findings Include: Resident #97 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's disease, Type II Diabetes, Major Depressive Disorder, Restless Leg Syndrome, Sleep Apnea, and Reflux, Osteoarthritis. According to the admission Record the Resident was diagnosed with Dementia on 12/16/18 and Psychosis on 1/9/18 (a year after admission). [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview, facility documentation and clinical record review the facility failed to ensure Residents had (Pre admission Screening and Resident Review) PASARR for 1 Resident (#169) in a survey sample of 60 Residents. For Resident #169 the facility staff failed to ensure a PASARR was obtained prior to admission.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed for two residents (Resident #113 and Resident #179) of 60 sampled residents to meet professional standards of quality. 1. For Resident #113, the facility staff failed to administer the correct physician ordered dose of oxygen. 2. For Resident #179, the facility staff failed to identify, assess, or treat a potential bowel elimination problem according to professional standards.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide quality of care to 3 Residents (Resident #94, Resident #113, and Resident #179) in a survey sample of 60 Residents. 1. For Resident #94, the facility staff failed to apply adaptive devices as ordered by the physician. 2. For Resident #113, the facility staff failed to ensure that physician ordered continuous oxygen was available prior to transport from her room to the dining room. 3. For Resident #179, the facility staff failed to identify, assess, or treat a potential bowel elimination problem.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, clinical record review, facility document review, and staff interview, the facility staff failed to provide services to prevent a decline in ROM (range of motion), and to increase range or motion, or prevent further decrease in ROM for one resident (Resident #14) in a survey sample of 60 Residents. For Resident #14, who was not admitted with contractures, the facility staff failed to provide ongoing assessment, services, equipment, and assistance, to maintain Range of Motion, or to prevent a further decline in ROM.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to prevent a Significant Weight Loss for 2 (Resident #192 and #65) of 60 residents and maintain fluids for 1 (Resident #11) of 60 residents. 1. The facility staff failed to prevent a Significant Weight Loss of 10.59% within 34 days. In addition, the facility staff failed to recognize, evaluate and address Resident #192's nutritional needs in a timely manner. 2. For Resident # 65 the facility failed to prevent wt. loss of 10.5% in two months. 3. For Resident #11 the facility staff failed to provide fluids in the amounts ordered by physician.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on staff interview, Resident interview and clinical record and facility documentation the facility staff failed to ensure Resident are provided adequate behavioral health services for 1 Residents (#180) in a survey sample of 60 Residents. For Resident # 180 the facility failed to provide adequate behavioral health services to prevent or manage behaviors exhibited by Resident #180.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on staff interview, resident interview, facility documentation and clinical record review the facility staff failed address psychosocial concerns for 1 Resident (#194) in a survey sample of 60 Residents. For Resident #194 the facility staff failed to provide adequate behavioral health services after a traumatic experience, leaving Resident #194 feeling unsafe at night.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure medications were available for administration for one Resident (Resident # 128) in a survey sample of 60 residents. For Resident #128, several medications were unavailable for administration including, but not limited to: the breathing treatment medication Acetylcysteine Solution 20%, the thyroid medication- Levothyroxine 50 micrograms and the mood disorder medication, Depakote 250 milligrams.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, staff interview, and facility documentation review the facility staff failed to provide a nourishing, well-balanced diet for three Residents (Resident #108, Resident #140, Resident #105) in a survey sample of 60 Residents. 1. For Resident #108, the facility staff ran out of food and failed to provide a well-balanced meal. 2. For Resident #140, the facility staff ran out of food and failed to provide a well-balanced meal. 3. For Resident #105, the facility staff ran out of food and failed to provide a well-balanced meal.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide food that accommodated resident needs for one resident (Resident #451) in a sample size of 60 residents. The facility staff served eggs to Resident #451 and she had an egg allergy.
March 16, 2018Standard inspection · 7 citations
- E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on staff interview, facility documentation review and clinical record, the facility staff failed to ensure 5 residents (Residents # 106, 115, 175, 30, and 95) were assessed (Level I) (1) or referred for Level II (2) PASARR (Preadmission Screening and Resident Review) after development of mental disorders. 1. For Resident # 106, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders. 2. Resident #115's PASARR was not dated. 3. Resident #175 did not receive a PASARR (preadmission screening and resident review) on admission. 4. Resident #30 did not have a Level I PASARR on admission. 5. For Resident #95, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed for 8 residents (Resident #176, #55, #149, #193, #115, #8, #175, #93) of the survey sample of 37 to ensure a PASARR screening was conducted prior to admission to the nursing facility. 1. For Resident #176, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 2. For Resident #55, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 3. For Resident #149, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 4. For Resident #193, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 5. [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed for 2 residents (#151, #95) in the sample size of 37 residents to provide facility sponsored individualized activities. 1. For Resident #151, the facility staff failed to provide individual activities. 2. For Resident #95, the facility staff failed to provide individual activities.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review the facility staff failed for 1 resident (Resident #189) of 37 residents in the survey sample to ensure appropriate services were provided to prevent urinary tract infections. 1. Resident #189's catheter drainage bag and tubing were observed on the floor while resident was sleeping in bed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, facility documentation review, clinical record review, the facility staff failed to to administer oxygen in a manner to prevent the spread of infection for one Resident (Resident # 15). For Resident # 15, on 03/13/18 the oxygen tubing was not dated as to when it had been changed.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed for 1 resident (Resident #103 ) of 37 residents in the survey sample to ensure medications were available for administration. For Resident #103, the breathing treatment medication Acetylcysteine Solution 20% was unavailable for administration.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident # 151) in the survey sample of 37 residents, to review and renew a PRN (as needed) order for psychotropic medication every 14 days. The facility staff failed to review and renew a PRN order for Ativan for approximately 7 months. During that time, the order was never limited to 14 days duration.
Fire safety inspections
24 fire safety citations on file: 1 on February 7, 2023, 7 on April 30, 2019, 16 on March 16, 2018.
Every fire safety citation24 citations
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 7, 2023 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · April 30, 2019 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 30, 2019 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 30, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 30, 2019 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · April 30, 2019 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · April 30, 2019 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 30, 2019 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · March 16, 2018 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 16, 2018 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 16, 2018 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 16, 2018 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 16, 2018 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · March 16, 2018 · Waiver
- E
Have simulated fire drills held at unexpected times.
K 712 · March 16, 2018 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 16, 2018 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 16, 2018 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · March 16, 2018 · Corrected (the home has a date of correction)
- D
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · March 16, 2018 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 16, 2018 · Waiver
- D
Have restrictions on the use of flammable curtains.
K 751 · March 16, 2018 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · March 16, 2018 · Corrected (the home has a date of correction)
- C
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 16, 2018 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 16, 2018 · Corrected (the home has a date of correction)