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 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
25D
8E
6F
Potential for minimal harm
0A
0B
1C
December 30, 2024Standard inspection · 2 citations
- 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 wroteThe facility had a census of 62 residents, The sample included 16 residents. Based on observation, record review, and interview, the facility failed to store and label medications in accordance with professional standards of practice. This placed the residents at risk of medication error.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility had a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure ice was maintained in a sanitary manner and failed to implement Enhanced Barrier Precautions (EBP-an infection control practice that uses personal protective equipment (PPE) to reduce the spread of multi-drug resistant organisms (MDRO) for Resident (R) 41 and R6 who had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). These deficient practices placed the residents at risk of contracting or spreading infectious processes.
July 15, 2024Complaint inspection · 1 citation
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility identified a census of 73 residents. The sample included five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure staff provided consistent bathing and/or showers for five sampled residents, Resident (R) 1, R2, R3, R4, and R5. This deficient practice placed the residents at risk for impaired dignity, infection, and alteration in skin integrity.
April 16, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThe facility identified a census of 73 residents with three residents reviewed for abuse and neglect. Based on record review, observation and interview, the facility failed to ensure Resident (R) 1 remained free from verbal abuse and/or mistreatment from staff. This deficient practice placed R1 at risk for fear, intimidation and neglect.
December 12, 2023Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThe facility identified a census of 63 resident with three residents reviewed for quality care and treatment. Based on record review, observation, and interview, the facility failed to provide quality care and treatment for Resident (R) 1 when staff failed to apply ACE wraps to R1's bilateral legs daily for lymphedema (swelling caused by accumulation of lymph). This deficient practice placed R1 at risk for edema (swelling), skin infections, and skin breakdown.
May 4, 2023Standard inspection · 25 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents, with four reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent ulcers for two sampled residents: Resident (R) 54, who obtained a facility acquired stage 3 (full thickness tissue loss) and R208, who obtained a facility acquired stage 2 (shallow with a reddish base) pressure ulcer. The facility further failed to ensure weekly monitoring of skin conditions to assess wound status including wound bed, healing, and effectiveness of treatments for R54 and R208. This deficient practice placed those residents at risk for delayed healing or worsened wounds.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to supervise cognitively impaired Resident, R 36, who exited the North Court Yard door, fell, and obtained a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on her forehead. This deficient practice placed R36 at risk for further falls and avoidable injuries.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents. Based on observation and interview the facility failed to employ a full-time Certified Dietary Manager (CDM) for the 60 residents who resided at the facility and received meals from the facility kitchen. This placed the resident at risk for receiving inadequate nutrition.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to prepare, store, and serve food in accordance with professional standards for food service safety for the 60 residents who resided in the facility and received their food from the facility kitchen, when facility failed to ensure clean and sanitary food prep areas. The facility staff failed to change gloves after touching her glasses, other objects, then picked up bread with the same contaminated gloves. The facility kitchen staff failed to order enough food for the noon meal and the facility staff failed to complete refrigerator logs. This placed the 60 residents at risk for foodborne illness.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteThe facility had a census of 70 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concerns for the 60 residents, who resided in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility had a census of 60 residents. Based on observation, interview, and record review the facility failed to provide proper infection control when using the same glucometer without disinfecting it between residents, delivering linens throughout the facility in an uncovered cart, during urinary catheter care, while providing oxygen therapy, and filling resident's used water mugs with ice while holding the used mug inside the ice bin. This deficient practice placed the residents of the facility at risk for infections.
- F
Keep all essential equipment working safely.
Inspectors wroteThe facility had a census of 60 residents. Based on observation, interview, and record review the facility failed to ensure essential equipment in the kitchen was maintained in safe operating condition with two ovens and the plate warmer out of service.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to act promptly, investigate, and resolve grievances and recommendations of six resident council members (Resident (R)14, R13, R15, R29, R42 and R212). This placed the five resident council members at risk for depression from unsolved concerns.
- 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 wroteThe facility had a census of 60 residents. Based on observation, interview, and record review the facility failed to date one insulin pen when opened and monitor refrigerator temperatures for two of two medication rooms. This deficient practice placed Resident (R) 26 at risk to receive outdated insulin and residents to receive temperature compromised medications.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteThe facility had a census of 60 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing four residents' pureed diets. This deficient practice placed the four residents at risk for impaired nutrition.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteThe facility had a census of 60 residents. Based on observation, record review, and interview the facility failed to ensure no more than a 14-hour lapse between a substantial evening meal and breakfast the following day, when staff failed to provide the 60 residents who resided in the facility a nourishing snack at bedtime. This placed the residents at risk for impaired nutrition.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wrote- The Electronic Medical Record (EMR) for R34 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal care, other symptoms and signs involving cognitive functions and awareness, and other symptoms and signs involving appearance and behavior. R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had severely impaired cognition, and required extensive assistance of two staff for personal hygiene, toileting, dressing, transfers, and bed mobility. The MDS further documented R34 required extensive assistance of one staff for eating. [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteThe facility had a census of 60 residents, with three reviewed for Center for Medicare and Medicated Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide CMS Form 10055, Advanced Beneficiary Notice (ABN), which included the estimated cost to continue services for skilled services to the resident or their representative for three resident:, Resident (R) 28, R47, and R56. This deficient practice placed all three residents at risk for unanticipated costs related to skilled services.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteThe facility had a census of 60 residents. The sample included one resident reviewed for exploitation. Based on observation, interview, and record review the facility failed to ensure Resident (R) 35 was free from staff misappropriation of her money when an employee of the facility used R35's credit card for unauthorized purchases. This deficient practice placed R35 at risk of exploitation.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to report to the state agency an unwitnessed fall with injury for Resident (R)36 who went outside without supervision, fell, and sustained a hematoma (a solid swelling of clotted blood within the tissues) on her forehead. This placed the resident at risk for further injury and unidentified abuse and mistreatment.
- D
Respond appropriately to all alleged violations.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate two sampled residents, Resident (R) 12, who received a skin tear to his forearm, and R36, who had a fall with injury. This placed the residents at risk for further injury and unidentified abuse or mistreatment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to revise care plans for five sampled residents, Resident (R)12's care plan for a skin tear, R36 who had 2 falls, R54 who had a facility acquired pressure ulcer, R9 who had venous ulcers (a shallow wound that develops on the lower leg when the leg veins fail to return blood back toward the heart normally) to her lower legs, and R25 for dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). This placed the residents at risk for unmet care needs.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents with one reviewed for transfer/discharge. Based on observation, record review, and interview the facility failed to implement discharge planning when Resident (R) 45 requested to return to the community. This placed the resident at risk for impaired psychosocial wellbeing.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility had a census of 60 residents, the sample included 17 residents, with two reviewed for activities of daily living (ADL). Based of observation, record review, and interview, the facility failed to provide appropriate cares to include grooming for Resident (R) 34, observed wearing dirty clothes for two out of four days on survey, and failed to assist R34 during meal service as he ate his meal with a knife only. This placed the resident at risk for poor hygiene and injury while eating with the knife.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents with one reviewed for positioning and two reviewed for skin issues. Based on observation, record review, and interview the facility staff failed to provide care and treatment in accordance with professional standards of practice when staff failed to monitor and provide care for Resident (R)9's venous ulcers (a shallow wound that develops on the lower leg when the leg veins fail to return blood back toward the heart normally) and staff failed to complete weekly skin assessments, and failed to change her lower legs dressing, when the odiferous serosanguinous drainage seeped through her to her outer dressing. Staff further failed to provide instructions for staff on how to care for R12's skin tear and/or to monitor her skin tear. Staff failed to reposition R44 when she leaned over to the right without support. [...]
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents, with one reviewed for hearing loss. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 45 received proper treatment and assistive devices to maintain his hearing ability when staff failed to follow up on R45's request to see an audiologist (physician who checks hearing loss). This placed the resident at risk for impaired communication.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents with one reviewed for dialysis. Based on observation, interview, and record review the facility failed to provide physician ordered care and services related to dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). This deficient practice placed Resident (R) 25 at risk for complications related to dialysis.
- 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 wroteThe facility had a census of 60 residents. The sample included 17 residents, with one reviewed for Post-Traumatic Stress Disorder (PTSD -psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). Based on observation, record review, and interview the facility failed to provide Resident (R)16 the appropriate treatment and services to attain her highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being, when staff failed to provide R16 with behavioral health services for PTSD. This placed the resident at risk for unmet mental health care needs.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteThe facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sampled resident, Resident (R) 43, who had behaviors. This placed the resident at risk for further decline of their emotional and mental well-being.
- 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 wroteThe facility had a census of 60 residents. The sample included 17 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to place a stop date on Resident (R) 16's as needed (PRN) Ativan (class of medications that calm and relax people with excessive anxiety, nervousness, or tension). This placed the resident at risk for unnecessary medications and related complications.
November 15, 2021Standard inspection · 13 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide the necessary care and services to ensure the resident wore her leg immobilizer (a leg brace is a device used to immobilize a joint or body segment, restrict movement in a given direction, reduce weight bearing forces, or correct the shape of the body) during transfers as physician ordered for Resident (R) 33.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility had a census of 59 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve foods in a sanitary manner for the 42 residents who received food from the facility kitchen and in the dining room.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wrote- R46's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of one staff for dressing and limited assistance of one staff for toileting and personal hygiene. The ADL Care Area Assessment (CAA), dated 07/09/21, documented R46 was at risk for further decline in ADLs, falls, immobility, refused therapy and remained at a functional baseline. The ADL Care Plan, dated 08/13/21, directed staff to monitor, report a decline in abilities to assist with ADLs, and to provide assistance as needed. On 11/10/21 at 09:45 AM, observation revealed Certified Nurse Aide (CNA) M assisted the resident to the bathroom, pulled the resident's pants down and dried feces (waste material from the bowel) was hanging from the resident's perineum (area between the genitals and the anus). [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide reasonable accommodation of resident needs for one sampled Resident (R) 40, regarding a wheelchair footrest needing repaired or replaced.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents with three sampled for Medicare Part A Liability Notices. Based on record review and interview, the facility failed to provide one of three sampled residents (or their representative) the Advance Beneficiary Notices (ABN), forms 10055 and 10123 for discharge from skilled services, Resident (R) 37.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents with four reviewed for accidents. Based on observation, interview and record review the facility failed to review and revise the care plan to prevent further falls for one sampled Resident (R) 36.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents, with seven reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain grooming, and personal hygiene for two sampled residents, Resident (R) 9, R46, and failed to provide bathing for R22.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents with four reviewed for accidents. Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for Resident (R)36. This placed R36 at increased risk for falls and injuries related to falls.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents, with five reviewed for nutrition. Based on observation, interview and record review, the facility failed to provide Resident (R) 21, who had a history of weight loss, her breakfast meal and physician ordered supplement with meals on a consistent basis. This placed R21 at risk for further weight loss and complications related to decreased nutrition. The facility failed to provide the correct diet to R33, who received a regular diet and had a physician order pureed diet. This placed R33 at risk for choking and aspiration.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents with one reviewed for feeding tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) care and services. Based on observation, interview, and record review the facility failed to ensure competent nursing practice during the administration of medications via the feeding tube for sampled Resident (R) 34.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to identify and report to the Director of Nursing, facility medical director, and physician an inappropriate diagnosis for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R) 53.
- 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 wroteThe facility had a census of 59 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to identify an inappropriate diagnosis for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R) 53.
- C
Post nurse staffing information every day.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing schedule was posted for two of three days of the onsite survey.
Fire safety inspections
49 fire safety citations on file: 15 on December 30, 2024, 14 on May 4, 2023, 20 on November 15, 2021.
Every fire safety citation49 citations
- F
Provide primary/alternate means for communication.
E 32 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of highly flammable decorations.
K 753 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · December 30, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · May 4, 2023 · Corrected (the home has a date of correction)
- F
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 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 4, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 4, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of flammable curtains.
K 751 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · November 15, 2021 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · November 15, 2021 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 15, 2021 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 15, 2021 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · November 15, 2021 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 15, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · November 15, 2021 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 15, 2021 · Corrected (the home has a date of correction)