HILLTOP PARK POST ACUTE Nursing Home


HILLTOP PARK POST ACUTE (CCN: 065241) is a Non profit - Corporation facility located in DENVER, CO (80224). The facility has an overall rating of 2/5, health inspection rating of 2/5, and a staffing rating of 2/5. It offers 160 certified beds and maintains an average of 88.5 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.18677 total hours per resident per day. It has been certified since August 1, 1988 and the last listed health inspection was on December 15, 2022, The facility is located in Denver county and provides senior and nursing home care.

HILLTOP PARK POST ACUTE Summary


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Provider Name: HILLTOP PARK POST ACUTE

Address: 290 S MONACO PKWY, DENVER, CO 80224

Phone: (303) 355-2525

County: Denver (150)

Ownership Type: Non profit - Corporation

Certified Beds: 160

Average Residents Per Day: 88.5 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: Legal Business Name Not Available

First Approved Date: August 1, 1988

Affiliated Entity: ()

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 2 ()

Health Inspection Rating: 2 ()

QM Rating: 4 ()

Long Stay QM Rating: 4 ()

Short Stay QM Rating: (2)

Staffing Rating: 2 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.54217, LPN Staff Hours Per Day: 0.6948, RN Staff Hours Per Day: 0.9497, Licensed Staff Hours Per Day: 1.6446

Total Nurse Staff Hours Per Day, per resident: 3.18677

Weekend Nurse Staff Hours: 2.76639, Weekend RN Staff Hours: 0.7266

PT Staff Hours Per Day, per resident: 0.0654

Nurse Staff Turnover: 62.6, Nurse Turnover Note:

RN Turnover: 63.0, RN Turnover Note:

Admin Left Number: 2, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.9433, Case Mix LPN Hours Per Day: 0.6876, Case Mix RN Hours Per Day: 0.3038

Adjusted Nurse Aide Hours Per Day, per resident: 1.61665, Adjusted LPN Hours Per Day: 0.7457, Adjusted RN Hours Per Day: 1.1779

Total Adjusted Nurse Hours Per Day, per resident: 3.42261

Adjusted Weekend Nurse Hours Per Day, per resident: 2.97111

Health Survey Dates and Scores: Cycle 1: 2022-12-15 (Score: 48), Cycle 2: 2021-08-26 (Score: 92), Cycle 3: 2020-03-05 (Score: 232)

Total Weighted Health Score: 93.333

Reported Incidents: 1, Substantiated Complaints: 15

Infection Control Citations: 2

Fines and Penalties: Number of Fines: 24, Total Fines in Dollars: 207360.27, Payment Denials Number: 0, Total Penalties Number: 24

Location and GPS: 290 S MONACO PKWY,DENVER,CO,80224 (39.7117, -104.913)

Process Date: 2024-03-01


Health Inspection Citations Details

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:

Citation on 2023-09-28

Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.

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 2023-11-17

Citation on 2023-10-25

Type: Health, Deficiency: PASARR screening for Mental disorders or Intellectual Disabilities

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 2023-11-11

Citation on 2023-03-01

Type: Health, Deficiency: Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

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 2023-03-24

Citation on 2023-03-01

Type: Health, Deficiency: Provide care by qualified persons according to each resident's written plan of care.

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 2023-03-24

Citation on 2022-12-15

Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

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 2023-02-24

Citation on 2022-12-15

Type: Health, Deficiency: PASARR screening for Mental disorders or Intellectual Disabilities

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 2023-02-15

Citation on 2022-12-15

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 2023-01-10

Citation on 2022-12-15

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

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 2023-02-24

Citation on 2022-12-15

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 2023-02-24

Citation on 2022-09-20

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-10-20

Citation on 2022-05-26

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 2022-07-09

Citation on 2022-05-26

Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.

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 2022-07-09

Citation on 2021-08-26

Type: Health, Deficiency: PASARR screening for Mental disorders or Intellectual Disabilities

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 2021-09-30

Citation on 2021-08-26

Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is 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 2021-09-30

Citation on 2021-08-26

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-30

Citation on 2021-08-26

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 2021-09-30

Citation on 2021-08-26

Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-30

Citation on 2021-08-26

Type: Health, Deficiency: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 2021-09-30

Citation on 2021-08-26

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 2021-09-17

Citation on 2022-02-24

Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.

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 2022-03-23

Citation on 2022-02-24

Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is 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 2022-03-23

Citation on 2022-02-24

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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 2022-03-23

Citation on 2022-02-24

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 2022-03-23

Citation on 2021-04-07

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: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has plan of correction on 2021-05-01

Citation on 2020-03-05

Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 2020-06-09

Citation on 2020-03-05

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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 2020-06-09

Citation on 2020-03-05

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 2020-06-09

Citation on 2020-03-05

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: 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 2020-06-09

Citation on 2020-03-05

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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 2020-06-09

Citation on 2020-03-05

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: PASARR screening for Mental disorders or Intellectual Disabilities

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Provide activities to meet all resident's 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 2020-06-09

Citation on 2020-03-05

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 2020-06-09

Citation on 2020-03-05

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: 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.

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

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 2020-06-09

Citation on 2020-03-05

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: 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 2020-06-09

Citation on 2020-03-05

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 2020-06-09

Citation on 2020-03-05

Type: Health, Deficiency: Have a plan that describes the process for conducting QAPI and QAA activities.

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 2020-06-09

Citation on 2020-03-05

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 2020-06-09


Fire Safety Citations Details

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:

Citation on 2023-01-04

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

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 2023-04-03

Citation on 2023-01-04

Type: Fire Safety, Tag: 0331, Version: New

Description: Construct fire resistant interior walls.

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 2023-01-27

Citation on 2023-01-04

Type: Fire Safety, Tag: 0355, Version: New

Description: Properly select, install, inspect, or maintain portable fire extinguishes.

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 2023-02-07

Citation on 2023-01-04

Type: Fire Safety, Tag: 0374, Version: New

Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.

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 2023-01-27

Citation on 2023-01-04

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

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 2023-03-02

Citation on 2023-01-04

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

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 2023-02-06

Citation on 2023-01-04

Type: Fire Safety, Tag: 0781, Version: New

Description: Have restrictions on the use of portable space heaters.

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 2023-02-06

Citation on 2023-01-04

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 2023-01-25

Citation on 2021-09-21

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 2021-12-06

Citation on 2021-09-21

Type: Fire Safety, Tag: 0227, Version: New

Description: Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

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 2021-12-06

Citation on 2021-09-21

Type: Fire Safety, Tag: 0271, Version: New

Description: Have exits that are accessible at all times.

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 2021-12-06

Citation on 2021-09-21

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: 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 2021-12-06

Citation on 2021-09-21

Type: Fire Safety, Tag: 0325, Version: New

Description: Have properly installed hallway dispensers for alcohol-based hand rub.

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 2021-12-06

Citation on 2021-09-21

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

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 2021-12-15

Citation on 2021-09-21

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

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 2021-12-06

Citation on 2021-09-21

Type: Fire Safety, Tag: 0371, Version: New

Description: Have properly sized and located compartments to protect residents from smoke.

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 2021-12-06

Citation on 2021-09-21

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 2021-12-06

Citation on 2020-09-03

Type: Fire Safety, Tag: 0211, Version: New

Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.

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 2020-12-17

Citation on 2020-09-03

Type: Fire Safety, Tag: 0222, Version: New

Description: 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.

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 2020-12-17

Citation on 2020-09-03

Type: Fire Safety, Tag: 0223, Version: New

Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0233, Version: New

Description: Install resident room doors of proper design and width.

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0271, Version: New

Description: Have exits that are accessible at all times.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Waiver has been granted on 2020-12-18

Citation on 2020-09-03

Type: Fire Safety, Tag: 0281, Version: New

Description: Install proper backup exit lighting.

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0291, Version: New

Description: Install emergency lighting that can last at least 1 1/2 hours.

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0293, Version: New

Description: Have properly located and lighted "Exit" signs.

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0331, Version: New

Description: Construct fire resistant interior walls.

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0345, Version: New

Description: Have approved installation, maintenance and testing program for fire alarm systems.

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 2020-10-14

Citation on 2020-09-03

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

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 2020-12-16

Citation on 2020-09-03

Type: Fire Safety, Tag: 0362, Version: New

Description: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

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 2020-12-21

Citation on 2020-09-03

Type: Fire Safety, Tag: 0371, Version: New

Description: Have properly sized and located compartments to protect residents from smoke.

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 2020-10-16

Citation on 2020-09-03

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 2020-10-14

Citation on 2020-09-03

Type: Fire Safety, Tag: 0930, Version: New

Description: Ensure proper storage of liquid oxygen.

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 2020-10-14