Provider Name: LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP
Address: 3002 ROWENA AVENUE, LOS ANGELES, CA 90039
Phone: (323) 666-1544
County: Los Angeles (200)
Ownership Type: For profit - Corporation
Certified Beds: 131
Average Residents Per Day: 117. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: Legal Business Name Not Available
First Approved Date: February 15, 1973
Affiliated Entity: COUNTRY VILLA HEALTH SERVICES (165)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: Y
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 2 ()
Health Inspection Rating: 1 ()
QM Rating: 5 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 3 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.41761, LPN Staff Hours Per Day: 1.0139, RN Staff Hours Per Day: 0.3478, Licensed Staff Hours Per Day: 1.3618
Total Nurse Staff Hours Per Day, per resident: 3.77943
Weekend Nurse Staff Hours: 3.61760, Weekend RN Staff Hours: 0.2766
PT Staff Hours Per Day, per resident: 0.0490
Nurse Staff Turnover: 42.3, Nurse Turnover Note:
RN Turnover: 72.7, RN Turnover Note:
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.0039, Case Mix LPN Hours Per Day: 0.7147, Case Mix RN Hours Per Day: 0.3571
Adjusted Nurse Aide Hours Per Day, per resident: 2.45780, Adjusted LPN Hours Per Day: 1.0469, Adjusted RN Hours Per Day: 0.3669
Total Adjusted Nurse Hours Per Day, per resident: 3.87307
Adjusted Weekend Nurse Hours Per Day, per resident: 3.70723
Health Survey Dates and Scores: Cycle 1: 2022-04-08 (Score: 188), Cycle 2: 2019-04-08 (Score: 148), Cycle 3: 2018-04-30 (Score: 88)
Total Weighted Health Score: 158.00
Reported Incidents: 13, Substantiated Complaints: 24
Infection Control Citations: 3
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 655.14, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 3002 ROWENA AVENUE,LOS ANGELES,CA,90039 (34.1087, -118.270)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-02
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-02-02
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-31
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-25
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-02
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-14
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-14
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-22
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-16
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-25
Type: Health, Deficiency: Ensure that residents are free from significant medication errors.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-22
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-20
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-20
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-10
Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Keep residents' personal and medical records private and confidential.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Plan the resident's discharge to meet the resident's goals and needs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Provide appropriate foot care.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Ensure that residents are free from significant medication errors.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-12-01
Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-12-01
Type: Health, Deficiency: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-12-01
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-20
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-16
Type: Health, Deficiency: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-19
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-15
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-02
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-03-21
Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: 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.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-01
Type: Health, Deficiency: Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-12-15
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-23
Type: Health, Deficiency: Ensure that residents are fully informed and understand their health status, care and treatments.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Type: Health, Deficiency: Have enough outside ventilation via a window or mechanical ventilation, or both.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-14
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0111, Version: New
Description: Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-25
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0291, Version: New
Description: Install emergency lighting that can last at least 1 1/2 hours.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0322, Version: New
Description: Ensure that laboratories employing quantities of flammable, combustible, or hazardous materials have fire resistant walls and automatic sprinkler system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0351, Version: New
Description: Install an approved automatic sprinkler system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0741, Version: New
Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0925, Version: New
Description: Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-28
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-20
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-20
Type: Fire Safety, Tag: 0009, Version: New
Description: Include a process for Emergency Preparedness collaboration.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0022, Version: New
Description: Establish policies and procedures for sheltering.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0023, Version: New
Description: Establish policies and procedures for medical documentation.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0029, Version: New
Description: Develop a communication plan.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0035, Version: New
Description: Provide family notifications of emergency plan.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0036, Version: New
Description: Establish emergency prep training and testing.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0351, Version: New
Description: Install an approved automatic sprinkler system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0741, Version: New
Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29
Type: Fire Safety, Tag: 0925, Version: New
Description: Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-06-29