EAGLE CLIFF MANOR Nursing Home


EAGLE CLIFF MANOR (CCN: 275123) is a For profit - Limited Liability company facility located in BILLINGS, MT (59105). The facility has an overall rating of 1/5, health inspection rating of 2/5, and a staffing rating of 1/5. It offers 129 certified beds and maintains an average of 52.9 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 2.75656 total hours per resident per day. It has been certified since April 1, 1988 and the last listed health inspection was on October 26, 2023, The facility is located in Yellowstone county and provides senior and nursing home care.

EAGLE CLIFF MANOR Summary


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

Provider Name: EAGLE CLIFF MANOR

Address: 1415 YELLOWSTONE RIVER RD, BILLINGS, MT 59105

Phone: (406) 245-9330

County: Yellowstone (550)

Ownership Type: For profit - Limited Liability company

Certified Beds: 129

Average Residents Per Day: 52.9 ()

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

Legal Business Name: LANTIS ENTERPRISES, INC

First Approved Date: April 1, 1988

Affiliated Entity: LANTIS ENTERPRISES (304)

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: 2 ()

Short Stay QM Rating: (2)

Staffing Rating: 1 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.62006, LPN Staff Hours Per Day: 0.7555, RN Staff Hours Per Day: 0.3809, Licensed Staff Hours Per Day: 1.1365

Total Nurse Staff Hours Per Day, per resident: 2.75656

Weekend Nurse Staff Hours: 2.54784, Weekend RN Staff Hours: 0.2179

PT Staff Hours Per Day, per resident: 0.0088

Nurse Staff Turnover: 79.2, Nurse Turnover Note:

RN Turnover: 60.0, RN Turnover Note:

Admin Left Number: , Admin Turnover Note: 6

Case Mix Nurse Aide Hours Per Day, per resident: 1.8134, Case Mix LPN Hours Per Day: 0.6466, Case Mix RN Hours Per Day: 0.2821

Adjusted Nurse Aide Hours Per Day, per resident: 1.81997, Adjusted LPN Hours Per Day: 0.8622, Adjusted RN Hours Per Day: 0.5087

Total Adjusted Nurse Hours Per Day, per resident: 3.16843

Adjusted Weekend Nurse Hours Per Day, per resident: 2.92852

Health Survey Dates and Scores: Cycle 1: 2023-10-26 (Score: 112), Cycle 2: 2023-01-05 (Score: 64), Cycle 3: 2022-01-20 (Score: 24)

Total Weighted Health Score: 109.33

Reported Incidents: 5, Substantiated Complaints: 1

Infection Control Citations:

Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 25025.00, Payment Denials Number: 0, Total Penalties Number: 2

Location and GPS: 1415 YELLOWSTONE RIVER RD,BILLINGS,MT,59105 (45.8183, -108.449)

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 2023-10-26

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 2023-11-25

Citation on 2023-10-26

Type: Health, Deficiency: Keep residents' personal and medical records private and confidential.

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

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 2023-11-25

Citation on 2023-10-26

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 2023-12-11

Citation on 2023-10-26

Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

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 2023-11-25

Citation on 2023-10-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

Type: Health, Deficiency: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

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 2023-11-25

Citation on 2023-10-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-10-26

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 2023-12-22

Citation on 2023-01-05

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-05

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 2023-02-02

Citation on 2023-01-05

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 2023-02-02

Citation on 2023-01-05

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 2023-02-02

Citation on 2023-01-05

Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-05

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 2023-02-02

Citation on 2023-01-05

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 2023-02-02

Citation on 2023-01-05

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 2023-02-02

Citation on 2023-01-05

Type: Health, Deficiency: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Severity: 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 2023-02-02

Citation on 2023-01-05

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-05

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-05

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

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

Corrected: Deficient, Provider has plan of correction on 2023-01-27

Citation on 2022-01-20

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 2022-02-10

Citation on 2022-01-20

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 2022-02-10

Citation on 2022-01-20

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 2022-02-10


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 2023-11-01

Type: Fire Safety, Tag: 0030, Version: New

Description: List the names and contact information of those in the facility.

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 2023-11-25

Citation on 2023-11-01

Type: Fire Safety, Tag: 0037, Version: New

Description: Establish staff and initial training 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 2023-11-25

Citation on 2023-11-01

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 2023-11-30

Citation on 2023-11-01

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 2023-11-22

Citation on 2023-11-01

Type: Fire Safety, Tag: 0300, Version: New

Description: Meet other general requirements that are deficient.

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-11-01

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 2023-11-25

Citation on 2023-11-01

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

Description: Provide properly protected cooking facilities.

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-11-01

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 2023-11-25

Citation on 2023-11-01

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 2023-11-25

Citation on 2023-11-01

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 2023-11-25

Citation on 2023-11-01

Type: Fire Safety, Tag: 0921, Version: New

Description: Ensure that testing and maintenance of electrical equipment is performed.

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

Corrected: Deficient, Provider has date of correction on 2023-11-25

Citation on 2023-01-09

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 2023-02-02

Citation on 2023-01-09

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 2023-02-02

Citation on 2023-01-09

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

Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-09

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-09

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 2023-02-02

Citation on 2023-01-09

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

Description: Install an approved automatic sprinkler system.

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-09

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 2023-02-02

Citation on 2023-01-09

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-09

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 2023-02-02

Citation on 2023-01-09

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-02

Citation on 2023-01-09

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

Description: Have properly installed electrical wiring and gas equipment.

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 2023-02-02

Citation on 2023-01-09

Type: Fire Safety, Tag: 0525, Version: New

Description: Enure that solid fuel-burning fireplaces are not in patient sleeping areas.

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 2023-02-02

Citation on 2023-01-09

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 2023-02-02

Citation on 2023-01-09

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: 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 2023-02-02

Citation on 2023-01-09

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

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

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 2023-02-02

Citation on 2023-01-09

Type: Fire Safety, Tag: 0911, Version: New

Description: Meet requirements for the installation and maintenance of electrical 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 2023-02-02

Citation on 2023-01-09

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 2023-02-02

Citation on 2023-01-09

Type: Fire Safety, Tag: 0914, Version: New

Description: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

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 2023-02-02

Citation on 2023-01-09

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 2023-02-02

Citation on 2023-01-09

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

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 2023-02-02

Citation on 2022-01-24

Type: Fire Safety, Tag: 0036, Version: New

Description: Establish emergency prep training and testing.

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 2022-02-13

Citation on 2022-01-24

Type: Fire Safety, Tag: 0037, Version: New

Description: Establish staff and initial training 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 2022-02-13

Citation on 2022-01-24

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 2022-02-13

Citation on 2022-01-24

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: 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 2022-02-13

Citation on 2022-01-24

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 2022-02-13

Citation on 2022-01-24

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

Description: Install an approved automatic sprinkler system.

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

Corrected: Deficient, Provider has date of correction on 2022-02-13

Citation on 2022-01-24

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 2022-02-13

Citation on 2022-01-24

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 2022-02-13

Citation on 2022-01-24

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 2022-02-13

Citation on 2022-01-24

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 2022-02-13

Citation on 2022-01-24

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

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

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 2022-02-13

Citation on 2022-01-24

Type: Fire Safety, Tag: 0914, Version: New

Description: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

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 2022-02-13

Citation on 2022-01-24

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

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 2022-02-13