EASTVIEW MANOR CARE CENTER Nursing Home


EASTVIEW MANOR CARE CENTER (CCN: 265730) is a For profit - Limited Liability company facility located in TRENTON, MO (64683). The facility has an overall rating of 1/5, health inspection rating of 1/5, and a staffing rating of 1/5. It offers 90 certified beds and maintains an average of 83.8 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 1.64926 total hours per resident per day. It has been certified since March 11, 2002 and the last listed health inspection was on May 20, 2021, The facility is located in Grundy county and provides senior and nursing home care.

EASTVIEW MANOR CARE CENTER Summary


Patient Ratings
Please rate how you felt your loved one or yourself have been treated at Eastview Manor Care Center below to help others make a more informed decision. Thank you.
Current Rating: Loading...

Provider Name: EASTVIEW MANOR CARE CENTER

Address: 1622 EAST 28TH STREET, TRENTON, MO 64683

Phone: (660) 359-2251

County: Grundy (390)

Ownership Type: For profit - Limited Liability company

Certified Beds: 90

Average Residents Per Day: 83.8 ()

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

Legal Business Name: EASTVIEW MANOR, INC

First Approved Date: March 11, 2002

Affiliated Entity: RELIANT CARE MANAGEMENT (446)

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: 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: 1.08917, LPN Staff Hours Per Day: 0.4487, RN Staff Hours Per Day: 0.1113, Licensed Staff Hours Per Day: 0.5600

Total Nurse Staff Hours Per Day, per resident: 1.64926

Weekend Nurse Staff Hours: 1.54989, Weekend RN Staff Hours: 0.1120

PT Staff Hours Per Day, per resident: 0.0000

Nurse Staff Turnover: 55.3, Nurse Turnover Note:

RN Turnover: , RN Turnover Note: 6

Admin Left Number: , Admin Turnover Note: 6

Case Mix Nurse Aide Hours Per Day, per resident: 1.4177, Case Mix LPN Hours Per Day: 0.5771, Case Mix RN Hours Per Day: 0.2597

Adjusted Nurse Aide Hours Per Day, per resident: 1.56513, Adjusted LPN Hours Per Day: 0.5737, Adjusted RN Hours Per Day: 0.1615

Total Adjusted Nurse Hours Per Day, per resident: 2.30574

Adjusted Weekend Nurse Hours Per Day, per resident: 2.16681

Health Survey Dates and Scores: Cycle 1: 2021-05-20 (Score: 336), Cycle 2: 2020-03-12 (Score: 143), Cycle 3: 2019-01-31 (Score: 48)

Total Weighted Health Score: 307.66

Reported Incidents: 22, Substantiated Complaints: 52

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 4, Total Fines in Dollars: 140253.75, Payment Denials Number: 1, Total Penalties Number: 5

Location and GPS: 1622 EAST 28TH STREET,TRENTON,MO,64683 (40.0901, -93.603)

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 2023-08-31

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 2023-10-15

Citation on 2023-05-19

Type: Health, Deficiency: Plan the resident's discharge to meet the resident's goals and needs.

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 2023-06-19

Citation on 2021-05-20

Type: Health, Deficiency: Allow resident to participate in the development and implementation of his or her person-centered 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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Give residents a notice of rights, rules, services and charges.

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: The resident has the right to receive notices in a format and a language he or she understands.

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Ensure residents have reasonable access to and privacy in their use of communication methods.

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

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

Corrected: Deficient, Provider has date of correction on 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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

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 2021-05-20

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 2021-10-11

Citation on 2021-05-20

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: 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 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-10-11

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Have enough outside ventilation via a window or mechanical ventilation, or both.

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Put firmly secured handrails on each side of hallways.

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 2021-08-13

Citation on 2021-05-20

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

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 2021-08-13

Citation on 2021-05-20

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: 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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Provide immediate access to any 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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Honor the resident's right to organize and participate in resident/family groups in 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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Honor the resident's right to manage his or her financial affairs.

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

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 2021-05-20

Type: Health, Deficiency: Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

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 2021-05-20

Type: Health, Deficiency: Assure the security of all personal funds of residents deposited with 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 2021-08-13

Citation on 2021-05-20

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: 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 2021-05-20

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: 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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Provide activities to meet all resident's needs.

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 2021-05-20

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

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

Corrected: Deficient, Provider has date of correction on 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

Type: Health, Deficiency: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

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 2021-08-02

Citation on 2021-05-20

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

Severity: 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 2021-05-20

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2022-12-27

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 2023-01-30

Citation on 2022-10-21

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

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

Corrected: Deficient, Provider has date of correction on 2022-10-29

Citation on 2022-06-21

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 2022-08-05

Citation on 2022-05-06

Type: Health, Deficiency: Ensure residents have reasonable access to and privacy in their use of communication methods.

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 2022-06-15

Citation on 2022-04-22

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 2022-06-16

Citation on 2020-03-12

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

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 2020-05-15

Citation on 2020-03-12

Type: Health, Deficiency: Ensure residents have reasonable access to and privacy in their use of communication methods.

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 2020-05-15

Citation on 2020-03-12

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 2020-05-15

Citation on 2020-03-12

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 2020-05-15

Citation on 2020-03-12

Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.

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 2020-05-15

Citation on 2020-03-12

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 2020-05-15

Citation on 2020-03-12

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 2020-05-15

Citation on 2021-08-13

Type: Health, Deficiency: Provide activities to meet all resident's needs.

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 2019-01-31

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 2019-03-17

Citation on 2019-01-31

Type: Health, Deficiency: Assess the resident when there is a significant change in condition

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 2019-03-17

Citation on 2019-01-31

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 2019-03-17

Citation on 2019-01-31

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 2019-03-17

Citation on 2019-01-31

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

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 2019-03-17

Citation on 2019-01-31

Type: Health, Deficiency: Keep all essential equipment working 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 2019-03-17

Citation on 2019-01-31

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: 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 2019-03-17


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 2021-05-20

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 2021-10-11

Citation on 2021-05-20

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 2021-10-11

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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

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

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 2021-08-13

Citation on 2021-05-20

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

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

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 2021-08-13

Citation on 2021-05-20

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

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

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 2021-08-13

Citation on 2021-05-20

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

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

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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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

Description: Install corridor and hallway doors that block 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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-10-11

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-10-11

Citation on 2021-05-20

Type: Fire Safety, Tag: 0761, Version: New

Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

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 2021-05-20

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

Description: Have power receptacles that are properly grounded.

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 2021-05-20

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: Waiver has been granted on 2021-12-30

Citation on 2021-05-20

Type: Fire Safety, Tag: 0919, Version: New

Description: Meet requirements for the use of electrical 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 2021-08-13

Citation on 2021-05-20

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 2021-08-13

Citation on 2021-05-20

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 2021-10-11

Citation on 2020-03-12

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: 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 2020-05-15

Citation on 2019-01-31

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 2019-03-17

Citation on 2019-01-31

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 2019-03-17

Citation on 2019-01-31

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 2019-03-17

Citation on 2019-01-31

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

Description: Have power receptacles that are properly grounded.

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 2019-03-17

Citation on 2019-01-31

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

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 2019-03-17