BENTON REHAB & HCC Nursing Home


BENTON REHAB & HCC (CCN: 146121) is a For profit - Individual facility located in BENTON, IL (62812). The facility has an overall rating of 1/5, health inspection rating of 1/5, and a staffing rating of 1/5. It offers 67 certified beds and maintains an average of 29.0 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.81706 total hours per resident per day. It has been certified since March 5, 2008 and the last listed health inspection was on May 26, 2023, The facility is located in Franklin county and provides senior and nursing home care.

BENTON REHAB & HCC Summary


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Provider Name: BENTON REHAB & HCC

Address: 1409 NORTH MAIN STREET, BENTON, IL 62812

Phone: (618) 435-2712

County: Franklin (360)

Ownership Type: For profit - Individual

Certified Beds: 67

Average Residents Per Day: 29.0 ()

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

Legal Business Name: PETERSEN HEALTH OPERATIONS LLC

First Approved Date: March 5, 2008

Affiliated Entity: PETERSEN HEALTH CARE (399)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 1 ()

Health Inspection Rating: 1 ()

QM Rating: 1 ()

Long Stay QM Rating: 1 ()

Short Stay QM Rating: 2 ()

Staffing Rating: 1 (12)

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.48173, LPN Staff Hours Per Day: 0.9016, RN Staff Hours Per Day: 0.4336, Licensed Staff Hours Per Day: 1.3353

Total Nurse Staff Hours Per Day, per resident: 3.81706

Weekend Nurse Staff Hours: 3.37171, Weekend RN Staff Hours: 0.2375

PT Staff Hours Per Day, per resident: 0.0141

Nurse Staff Turnover: 61.5, Nurse Turnover Note:

RN Turnover: 80.0, RN Turnover Note:

Admin Left Number: 2, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.9554, Case Mix LPN Hours Per Day: 0.6846, Case Mix RN Hours Per Day: 0.3001

Adjusted Nurse Aide Hours Per Day, per resident: 2.58553, Adjusted LPN Hours Per Day: 0.9719, Adjusted RN Hours Per Day: 0.5444

Total Adjusted Nurse Hours Per Day, per resident: 4.09210

Adjusted Weekend Nurse Hours Per Day, per resident: 3.61466

Health Survey Dates and Scores: Cycle 1: 2023-05-26 (Score: 112), Cycle 2: 2022-07-08 (Score: 308), Cycle 3: 2021-09-23 (Score: 92)

Total Weighted Health Score: 225.33

Reported Incidents: 3, Substantiated Complaints: 12

Infection Control Citations:

Fines and Penalties: Number of Fines: 3, Total Fines in Dollars: 281937.20, Payment Denials Number: 2, Total Penalties Number: 5

Location and GPS: 1409 NORTH MAIN STREET,BENTON,IL,62812 (38.0114, -88.921)

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 2023-12-13

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 2023-12-20

Citation on 2023-12-13

Type: Health, Deficiency: Respond appropriately to all alleged violations.

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 2023-12-20

Citation on 2023-09-19

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: 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 2023-09-29

Citation on 2023-05-11

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 2023-06-09

Citation on 2023-05-11

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 2023-05-17

Citation on 2023-04-11

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 2023-05-08

Citation on 2023-04-11

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 2023-06-09

Citation on 2023-04-11

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 2023-05-08

Citation on 2023-05-26

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: 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 2023-06-09

Citation on 2023-05-26

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 2023-06-09

Citation on 2023-05-26

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 2023-06-09

Citation on 2023-05-26

Type: Health, Deficiency: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

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 2023-06-09

Citation on 2023-05-26

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

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 2023-06-09

Citation on 2023-05-26

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 2023-06-09

Citation on 2023-05-26

Type: Health, Deficiency: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

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 2023-06-09

Citation on 2023-05-26

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 2023-06-09

Citation on 2023-05-26

Type: Health, Deficiency: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Waiver has been granted on 2023-06-09

Citation on 2023-05-26

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 2023-06-09

Citation on 2023-01-27

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 2023-02-13

Citation on 2023-01-09

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 2023-02-01

Citation on 2023-01-09

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 2023-02-01

Citation on 2023-01-09

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 2023-02-01

Citation on 2023-01-09

Type: Health, Deficiency: Ensure that the resident and his/her doctor meet face-to-face at all required visits.

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 2023-02-01

Citation on 2023-01-09

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 2023-02-01

Citation on 2022-12-15

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 2022-12-23

Citation on 2022-12-15

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 2022-12-23

Citation on 2022-11-23

Type: Health, Deficiency: Protect each resident from the wrongful use of the resident's belongings or money.

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 2022-12-08

Citation on 2022-11-23

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 2023-02-01

Citation on 2022-11-23

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: 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 2023-02-01

Citation on 2022-07-08

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

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has plan of correction on 2022-07-28

Citation on 2022-07-08

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: 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 2022-07-28

Citation on 2022-07-08

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 2022-07-28

Citation on 2022-07-08

Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

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 2022-07-28

Citation on 2022-07-08

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

Citation on 2022-07-08

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 2022-10-18

Citation on 2022-07-08

Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.

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

Corrected: Deficient, Provider has date of correction on 2022-07-27

Citation on 2022-07-08

Type: Health, Deficiency: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

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 2022-10-18

Citation on 2022-07-08

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: 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 2022-07-28

Citation on 2022-07-08

Type: Health, Deficiency: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

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 2022-07-28

Citation on 2022-07-08

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 2022-07-28

Citation on 2022-07-08

Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

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 2022-09-07

Citation on 2022-07-08

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 2022-09-07

Citation on 2022-07-08

Type: Health, Deficiency: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

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 2022-08-10

Citation on 2022-07-08

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 2022-08-03

Citation on 2022-07-08

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 2022-10-18

Citation on 2022-07-08

Type: Health, Deficiency: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has plan of correction on 2022-07-28

Citation on 2022-07-08

Type: Health, Deficiency: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

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 2022-08-02

Citation on 2022-07-08

Type: Health, Deficiency: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

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 2022-08-02

Citation on 2022-07-08

Type: Health, Deficiency: Ensure that each resident is free from medications that restrain them, 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 2022-09-28

Citation on 2022-07-08

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

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 2022-07-28

Citation on 2022-07-08

Type: Health, Deficiency: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

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

Corrected: Deficient, Provider has date of correction on 2022-07-28

Citation on 2021-07-07

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 2021-07-25

Citation on 2021-07-07

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 2021-07-25

Citation on 2021-09-23

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 2021-10-11

Citation on 2021-09-23

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 2021-10-11

Citation on 2021-09-23

Type: Health, Deficiency: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

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 2021-10-11

Citation on 2021-09-23

Type: Health, Deficiency: Post nurse staffing information every day.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-11

Citation on 2021-09-23

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 2021-10-11

Citation on 2021-09-23

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 2021-10-11

Citation on 2021-09-23

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

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 2021-10-11

Citation on 2021-09-23

Type: Health, Deficiency: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-11

Citation on 2021-09-23

Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

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 2021-10-22


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 2023-05-30

Type: Fire Safety, Tag: 0039, Version: New

Description: Conduct testing and exercise requirements.

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 2023-06-15

Citation on 2023-05-30

Type: Fire Safety, Tag: 0041, Version: New

Description: Implement emergency and standby power 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 2023-06-15

Citation on 2023-05-30

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 2023-06-15

Citation on 2021-09-21

Type: Fire Safety, Tag: 0004, Version: New

Description: Develop and maintain an Emergency Preparedness Program (EP).

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 2021-10-10

Citation on 2021-09-21

Type: Fire Safety, Tag: 0015, Version: New

Description: Address subsistence needs for staff and patients.

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 2021-10-10

Citation on 2021-09-21

Type: Fire Safety, Tag: 0024, Version: New

Description: Establish policies and procedures for volunteers.

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 2021-10-10

Citation on 2021-09-21

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 2021-10-11

Citation on 2021-09-21

Type: Fire Safety, Tag: 0342, Version: New

Description: Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

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 2021-10-10

Citation on 2021-09-21

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 2021-10-10

Citation on 2021-09-21

Type: Fire Safety, Tag: 0347, Version: New

Description: Properly provide smoke detection systems in areas open to corridors.

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 2021-10-10

Citation on 2021-09-21

Type: Fire Safety, Tag: 0511, Version: New

Description: Have properly installed electrical wiring and gas equipment.

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 2021-10-11

Citation on 2021-09-21

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

Description: Have simulated fire drills held at unexpected times.

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 2021-10-10

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 2021-10-29

Citation on 2021-09-21

Type: Fire Safety, Tag: 0927, Version: New

Description: Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

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 2021-10-10