CORONADO RIDGE SKILLED NURSING & REHABILITATION CE Nursing Home


CORONADO RIDGE SKILLED NURSING & REHABILITATION CE (CCN: 295099) is a For profit - Corporation facility located in HENDERSON, NV (89052). The facility has an overall rating of 4/5, health inspection rating of 3/5, and a staffing rating of 3/5. It offers 121 certified beds and maintains an average of 106. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.56083 total hours per resident per day. It has been certified since December 4, 2017 and the last listed health inspection was on July 13, 2023, The facility is located in Clark county and provides senior and nursing home care.

CORONADO RIDGE SKILLED NURSING & REHABILITATION CE Summary


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Provider Name: CORONADO RIDGE SKILLED NURSING & REHABILITATION CE

Address: 2855 W. HORIZON RIDGE PARKWAY, HENDERSON, NV 89052

Phone: (702) 805-5050

County: Clark (010)

Ownership Type: For profit - Corporation

Certified Beds: 121

Average Residents Per Day: 106. ()

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

Legal Business Name: GHC OF HENDERSON LLC

First Approved Date: December 4, 2017

Affiliated Entity: GENERATIONS HEALTHCARE (236)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 4 ()

Health Inspection Rating: 3 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 4 ()

Staffing Rating: 3 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.29562, LPN Staff Hours Per Day: 1.6728, RN Staff Hours Per Day: 0.5924, Licensed Staff Hours Per Day: 2.2652

Total Nurse Staff Hours Per Day, per resident: 4.56083

Weekend Nurse Staff Hours: 3.84686, Weekend RN Staff Hours: 0.2782

PT Staff Hours Per Day, per resident: 0.1416

Nurse Staff Turnover: 57.7, Nurse Turnover Note:

RN Turnover: 50.0, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.8243, Case Mix LPN Hours Per Day: 0.7624, Case Mix RN Hours Per Day: 0.4839

Adjusted Nurse Aide Hours Per Day, per resident: 2.56345, Adjusted LPN Hours Per Day: 1.6190, Adjusted RN Hours Per Day: 0.4612

Total Adjusted Nurse Hours Per Day, per resident: 4.68148

Adjusted Weekend Nurse Hours Per Day, per resident: 3.94862

Health Survey Dates and Scores: Cycle 1: 2023-07-13 (Score: 60), Cycle 2: 2022-04-01 (Score: 60), Cycle 3: 2019-12-12 (Score: 88)

Total Weighted Health Score: 64.667

Reported Incidents: 1, Substantiated Complaints: 3

Infection Control Citations: 2

Fines and Penalties: Number of Fines: 4, Total Fines in Dollars: 4596.80, Payment Denials Number: 0, Total Penalties Number: 4

Location and GPS: 2855 W. HORIZON RIDGE PARKWAY,HENDERSON,NV,89052 (35.9988, -115.111)

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 2023-07-13

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 2023-08-17

Citation on 2023-07-13

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 2023-08-17

Citation on 2023-07-13

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 2023-08-17

Citation on 2023-07-13

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 2023-08-17

Citation on 2023-07-13

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 2023-08-28

Citation on 2023-07-13

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 2023-08-17

Citation on 2023-07-13

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 2023-08-28

Citation on 2023-07-13

Type: Health, Deficiency: Provide a neutral and fair arbitration process and agree to arbitrator and venue.

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 2023-08-28

Citation on 2022-12-29

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 2023-02-16

Citation on 2022-12-29

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 2023-02-16

Citation on 2022-12-29

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: 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 2023-02-16

Citation on 2022-12-29

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 2023-02-16

Citation on 2022-06-21

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: 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 2022-06-21

Citation on 2022-04-01

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 2022-05-09

Citation on 2022-04-01

Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.

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

Corrected: Deficient, Provider has date of correction on 2022-05-09

Citation on 2022-04-01

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 2022-05-09

Citation on 2022-04-01

Type: Health, Deficiency: Provide appropriate foot care.

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 2022-05-09

Citation on 2022-04-01

Type: Health, Deficiency: Provide for the safe, appropriate administration of IV fluids 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 2022-05-09

Citation on 2022-04-01

Type: Health, Deficiency: Provide safe, appropriate dialysis care/services 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 2022-05-09

Citation on 2022-04-01

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 2022-05-09

Citation on 2022-04-01

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

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 2022-05-09

Citation on 2021-07-30

Type: Health, Deficiency: Perform COVID19 testing on residents and staff.

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 2021-08-16

Citation on 2021-10-07

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 2021-10-20

Citation on 2019-12-12

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

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

Corrected: Deficient, Provider has date of correction on 2020-01-10

Citation on 2019-12-12

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 2020-01-10

Citation on 2019-12-12

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

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

Corrected: Deficient, Provider has date of correction on 2020-01-10

Citation on 2019-12-12

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

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

Corrected: Deficient, Provider has date of correction on 2020-01-10

Citation on 2019-12-12

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 2020-01-10

Citation on 2019-12-12

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 2020-01-10

Citation on 2019-12-12

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 2020-01-10

Citation on 2019-12-12

Type: Health, Deficiency: Provide for the safe, appropriate administration of IV fluids for a resident when needed.

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

Corrected: Deficient, Provider has date of correction on 2020-01-10

Citation on 2019-12-12

Type: Health, Deficiency: Provide safe, appropriate dialysis care/services 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 2020-01-10

Citation on 2019-12-12

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: 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 2020-01-10

Citation on 2019-12-12

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 2020-01-10

Citation on 2019-12-12

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 2020-01-10

Citation on 2019-12-12

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: 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 2020-01-10

Citation on 2019-12-12

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

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

Corrected: Deficient, Provider has date of correction on 2020-01-10


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 2023-07-20

Type: Fire Safety, Tag: 0006, Version: New

Description: Conduct risk assessment and an All-Hazards approach.

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 2023-09-13

Citation on 2023-07-20

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

Description: Address subsistence needs for staff and patients.

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 2023-09-13

Citation on 2023-07-20

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

Description: List the names and contact information of those 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 2023-09-13

Citation on 2023-07-20

Type: Fire Safety, Tag: 0032, Version: New

Description: Provide primary/alternate means for communication.

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 2023-09-13

Citation on 2023-07-20

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

Description: Establish emergency prep training and testing.

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 2023-09-13

Citation on 2023-07-20

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

Description: Conduct testing and exercise 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 2023-09-13

Citation on 2023-07-20

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: 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 2023-10-05

Citation on 2023-07-20

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 2023-09-13

Citation on 2023-07-20

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 2023-10-05

Citation on 2023-07-20

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

Description: Construct fire resistant interior walls.

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 2023-09-13

Citation on 2023-07-20

Type: Fire Safety, Tag: 0344, Version: New

Description: Have an alternate power supply for its alarm system.

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

Corrected: Deficient, Provider has date of correction on 2023-09-13

Citation on 2023-07-20

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 2023-10-05

Citation on 2023-07-20

Type: Fire Safety, Tag: 0346, Version: New

Description: Follow proper procedures when the fire alarm was out of service for more than 4 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 2023-10-05

Citation on 2023-07-20

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 2023-10-05

Citation on 2023-07-20

Type: Fire Safety, Tag: 0354, Version: New

Description: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 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 2023-10-05

Citation on 2023-07-20

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

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

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 2023-09-13

Citation on 2023-07-20

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 2023-09-13

Citation on 2023-07-20

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 2023-10-05

Citation on 2023-07-20

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 2023-10-05

Citation on 2023-07-20

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-10-05

Citation on 2023-07-20

Type: Fire Safety, Tag: 0711, Version: New

Description: Provide a written emergency evacuation plan.

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 2023-09-13

Citation on 2023-07-20

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

Description: Have simulated fire drills held at unexpected times.

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

Corrected: Deficient, Provider has date of correction on 2023-09-13

Citation on 2023-07-20

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 2023-09-13

Citation on 2023-07-20

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 2023-10-05

Citation on 2023-07-20

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: Deficient, Provider has date of correction on 2023-09-13

Citation on 2023-07-20

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

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

Corrected: Deficient, Provider has date of correction on 2023-09-13

Citation on 2022-03-31

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

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

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 2022-05-02

Citation on 2022-03-31

Type: Fire Safety, Tag: 0006, Version: New

Description: Conduct risk assessment and an All-Hazards approach.

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 2022-05-02

Citation on 2022-03-31

Type: Fire Safety, Tag: 0013, Version: New

Description: Develop Emergency Preparedness policies and procedures.

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 2022-05-02

Citation on 2022-03-31

Type: Fire Safety, Tag: 0029, Version: New

Description: Develop a communication plan.

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 2022-05-02

Citation on 2022-03-31

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

Description: Establish emergency prep training and testing.

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 2022-05-02

Citation on 2022-03-31

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

Description: Implement emergency and standby power systems.

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 2022-04-01

Citation on 2022-03-31

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 2022-05-06

Citation on 2022-03-31

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

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

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 2022-04-01

Citation on 2022-03-31

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 2022-05-02

Citation on 2022-03-31

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

Description: Have properly installed electrical wiring and gas equipment.

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 2022-04-28

Citation on 2022-03-31

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

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

Severity: 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 2022-05-04

Citation on 2022-03-31

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

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

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 2022-04-01

Citation on 2019-12-12

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

Description: Address subsistence needs for staff and patients.

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 2020-01-27

Citation on 2019-12-12

Type: Fire Safety, Tag: 0020, Version: New

Description: Establish policies and procedures including evacuation.

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 2020-01-27

Citation on 2019-12-12

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

Description: Establish staff and initial training requirements.

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 2020-01-27

Citation on 2019-12-12

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

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

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 2020-01-27

Citation on 2019-12-12

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

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

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

Corrected: Deficient, Provider has date of correction on 2020-01-27

Citation on 2019-12-12

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

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

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 2020-01-27

Citation on 2019-12-12

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

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

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

Corrected: Deficient, Provider has date of correction on 2020-01-27

Citation on 2019-12-12

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 2020-01-27

Citation on 2019-12-12

Type: Fire Safety, Tag: 0522, Version: New

Description: Have an externally vented heating system.

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

Corrected: Deficient, Provider has date of correction on 2020-01-27

Citation on 2019-12-12

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 2020-01-27

Citation on 2019-12-12

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 2020-01-27