SPRING CREEK Nursing Home


SPRING CREEK (CCN: 146172) is a For profit - Corporation facility located in JOLIET, IL (60432). The facility has an overall rating of 1/5, health inspection rating of 2/5, and a staffing rating of 1/5. It offers 168 certified beds and maintains an average of 87.7 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 2.83073 total hours per resident per day. It has been certified since August 14, 2014 and the last listed health inspection was on December 18, 2023, The facility is located in Will county and provides senior and nursing home care.

SPRING CREEK Summary


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Provider Name: SPRING CREEK

Address: 777 DRAPER AVENUE, JOLIET, IL 60432

Phone: (815) 727-4794

County: Will (989)

Ownership Type: For profit - Corporation

Certified Beds: 168

Average Residents Per Day: 87.7 ()

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

Legal Business Name: SPRING CREEK SNF LLC

First Approved Date: August 14, 2014

Affiliated Entity: SABA HEALTHCARE (460)

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: 2 ()

QM Rating: 2 ()

Long Stay QM Rating: 3 ()

Short Stay QM Rating: 1 ()

Staffing Rating: 1 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.52339, LPN Staff Hours Per Day: 0.9877, RN Staff Hours Per Day: 0.3195, Licensed Staff Hours Per Day: 1.3073

Total Nurse Staff Hours Per Day, per resident: 2.83073

Weekend Nurse Staff Hours: 2.33531, Weekend RN Staff Hours: 0.1729

PT Staff Hours Per Day, per resident: 0.0203

Nurse Staff Turnover: 58.8, Nurse Turnover Note:

RN Turnover: 57.1, RN Turnover Note:

Admin Left Number: , Admin Turnover Note: 6

Case Mix Nurse Aide Hours Per Day, per resident: 1.9571, Case Mix LPN Hours Per Day: 0.7476, Case Mix RN Hours Per Day: 0.3563

Adjusted Nurse Aide Hours Per Day, per resident: 1.58573, Adjusted LPN Hours Per Day: 0.9749, Adjusted RN Hours Per Day: 0.3379

Total Adjusted Nurse Hours Per Day, per resident: 2.91475

Adjusted Weekend Nurse Hours Per Day, per resident: 2.40462

Health Survey Dates and Scores: Cycle 1: 2023-12-18 (Score: 138), Cycle 2: 2023-01-13 (Score: 80), Cycle 3: 2021-12-17 (Score: 64)

Total Weighted Health Score: 106.33

Reported Incidents: 0, Substantiated Complaints: 14

Infection Control Citations:

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 177975.00, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 777 DRAPER AVENUE,JOLIET,IL,60432 (41.5390, -88.055)

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 2023-09-14

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 2023-09-18

Citation on 2023-09-14

Type: Health, Deficiency: Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

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 2023-09-18

Citation on 2023-09-14

Type: Health, Deficiency: Help the resident make transportation arrangements to and from radiology 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 2023-09-18

Citation on 2023-07-21

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 2023-07-25

Citation on 2023-07-06

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 2023-07-13

Citation on 2023-05-23

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

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

Corrected: Deficient, Provider has date of correction on 2023-05-25

Citation on 2023-05-23

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: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-25

Citation on 2023-12-18

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 2023-12-21

Citation on 2023-12-18

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 2023-12-21

Citation on 2023-12-18

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 2023-12-21

Citation on 2023-12-18

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: 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 2023-12-21

Citation on 2023-12-18

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 2023-12-21

Citation on 2023-12-18

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 2023-12-21

Citation on 2023-01-25

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 2023-01-26

Citation on 2023-01-25

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 2023-01-26

Citation on 2022-11-22

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 2022-11-25

Citation on 2022-11-22

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 2022-11-25

Citation on 2022-08-08

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 2022-08-11

Citation on 2022-08-08

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 2022-08-11

Citation on 2022-08-04

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 2022-08-05

Citation on 2022-03-11

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 2022-03-24

Citation on 2023-01-13

Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.

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 2023-01-23

Citation on 2023-01-13

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 2023-01-23

Citation on 2023-01-13

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 2023-01-23

Citation on 2023-01-13

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 2023-01-23

Citation on 2023-01-13

Type: Health, Deficiency: Have a policy regarding use and storage of foods brought to residents by family and other visitors.

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 2023-01-23

Citation on 2023-01-13

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 2023-01-23

Citation on 2022-01-05

Type: Health, Deficiency: Assist a resident in gaining access to vision and hearing 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 2022-02-08

Citation on 2022-01-05

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 2022-02-08

Citation on 2021-12-17

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 2021-12-28

Citation on 2021-12-17

Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.

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 2021-12-28

Citation on 2021-12-17

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 2021-12-28

Citation on 2021-12-17

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 2021-12-28

Citation on 2021-12-17

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

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 2021-12-28

Citation on 2021-12-17

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 2021-12-28

Citation on 2021-12-17

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 2021-12-28

Citation on 2021-12-17

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 2021-12-28

Citation on 2021-12-17

Type: Health, Deficiency: Implement a program that monitors antibiotic use.

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 2021-12-28


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 2024-01-05

Type: Fire Safety, Tag: 0225, Version: New

Description: Have stairways and smokeproof enclosures used as exits 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 2024-01-08

Citation on 2024-01-05

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 2024-01-08

Citation on 2024-01-05

Type: Fire Safety, Tag: 0341, Version: New

Description: Install a fire alarm system that can be heard throughout the facility.

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 2024-01-08

Citation on 2024-01-05

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 2024-01-08

Citation on 2024-01-05

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 2024-01-08

Citation on 2024-01-05

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 2024-01-08

Citation on 2024-01-05

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

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 2024-01-08

Citation on 2024-01-05

Type: Fire Safety, Tag: 0754, Version: New

Description: Provide properly sized and located linen or trash receptacles.

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 2024-01-08

Citation on 2024-01-05

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 2024-01-08

Citation on 2023-01-24

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 2023-03-17

Citation on 2023-01-24

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: 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 2023-03-17

Citation on 2023-01-24

Type: Fire Safety, Tag: 0225, Version: New

Description: Have stairways and smokeproof enclosures used as exits 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 2023-03-17

Citation on 2023-01-24

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 2023-03-17

Citation on 2023-01-24

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 2023-03-17

Citation on 2023-01-24

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 2023-03-17

Citation on 2023-01-24

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

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 2023-03-17

Citation on 2023-01-24

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

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

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 2023-03-17

Citation on 2023-01-24

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 2023-03-17

Citation on 2023-01-24

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 2023-03-17

Citation on 2023-01-24

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 2023-03-17

Citation on 2023-01-24

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 2023-03-17

Citation on 2021-12-15

Type: Fire Safety, Tag: 0007, Version: New

Description: Address patient/client population and determine types of services needed.

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 2022-01-03

Citation on 2021-12-15

Type: Fire Safety, Tag: 0022, Version: New

Description: Establish policies and procedures for sheltering.

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 2022-01-03

Citation on 2021-12-15

Type: Fire Safety, Tag: 0161, Version: New

Description: Use approved construction type or materials.

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 2022-01-03

Citation on 2021-12-15

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 2022-01-03

Citation on 2021-12-15

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: 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 2022-01-03

Citation on 2021-12-15

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: 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 2022-01-03

Citation on 2021-12-15

Type: Fire Safety, Tag: 0225, Version: New

Description: Have stairways and smokeproof enclosures used as exits 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 2022-01-03

Citation on 2021-12-15

Type: Fire Safety, Tag: 0232, Version: New

Description: Have corridors or aisles that are unobstructed and are at least 8 feet in 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 2022-01-03

Citation on 2021-12-15

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 2022-01-03

Citation on 2021-12-15

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 2022-01-03

Citation on 2021-12-15

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

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

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 2022-01-03

Citation on 2021-12-15

Type: Fire Safety, Tag: 0351, Version: New

Description: Install an approved automatic sprinkler system.

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 2022-01-03

Citation on 2021-12-15

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 2022-01-03

Citation on 2021-12-15

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 2022-01-03

Citation on 2021-12-15

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 2022-01-03

Citation on 2021-12-15

Type: Fire Safety, Tag: 0912, Version: New

Description: Have power receptacles that are properly grounded.

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 2022-01-03

Citation on 2021-12-15

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 2022-01-03