CASA REAL Nursing Home


CASA REAL (CCN: 325038) is a For profit - Corporation facility located in SANTA FE, NM (87505). It is designated as a Special Focus Facility. The facility has an overall rating of 1/5, health inspection rating of 1/5, and a staffing rating of 1/5. It offers 118 certified beds and maintains an average of 107. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.02934 total hours per resident per day. It has been certified since January 10, 1985 and the last listed health inspection was on May 24, 2023, The facility is located in Santa Fe county and provides senior and nursing home care.

CASA REAL Summary


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Provider Name: CASA REAL

Address: 1650 GALISTEO STREET, SANTA FE, NM 87505

Phone: (505) 984-8313

County: Santa Fe (240)

Ownership Type: For profit - Corporation

Certified Beds: 118

Average Residents Per Day: 107. ()

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

Legal Business Name: 1650 GALISTEO STREET OPERATIONS LLC

First Approved Date: January 10, 1985

Affiliated Entity: GENESIS HEALTHCARE (237)

Retirement Community: N, Special Focus Status: SFF Candidate

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 1 ()

Health Inspection Rating: 1 ()

QM Rating: 1 ()

Long Stay QM Rating: 1 ()

Short Stay QM Rating: 2 ()

Staffing Rating: 1 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.96688, LPN Staff Hours Per Day: 0.7835, RN Staff Hours Per Day: 0.2788, Licensed Staff Hours Per Day: 1.0624

Total Nurse Staff Hours Per Day, per resident: 3.02934

Weekend Nurse Staff Hours: 2.72142, Weekend RN Staff Hours: 0.2318

PT Staff Hours Per Day, per resident: 0.0206

Nurse Staff Turnover: 63.5, Nurse Turnover Note:

RN Turnover: 86.7, RN Turnover Note:

Admin Left Number: 1, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.7193, Case Mix LPN Hours Per Day: 0.6796, Case Mix RN Hours Per Day: 0.3060

Adjusted Nurse Aide Hours Per Day, per resident: 2.33059, Adjusted LPN Hours Per Day: 0.8508, Adjusted RN Hours Per Day: 0.3434

Total Adjusted Nurse Hours Per Day, per resident: 3.53006

Adjusted Weekend Nurse Hours Per Day, per resident: 3.17124

Health Survey Dates and Scores: Cycle 1: 2023-05-24 (Score: 412), Cycle 2: 2022-03-23 (Score: 264), Cycle 3: 2020-12-30 (Score: 88)

Total Weighted Health Score: 308.66

Reported Incidents: 0, Substantiated Complaints: 11

Infection Control Citations: 1

Fines and Penalties: Number of Fines: 3, Total Fines in Dollars: 315850.96, Payment Denials Number: 2, Total Penalties Number: 5

Location and GPS: 1650 GALISTEO STREET,SANTA FE,NM,87505 (35.6620, -105.949)

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 2023-11-03

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

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

Corrected: Deficient, Provider has date of correction on 2023-12-12

Citation on 2023-09-29

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 2023-11-01

Citation on 2023-05-01

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 2023-06-22

Citation on 2023-05-01

Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.

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

Corrected: Deficient, Provider has date of correction on 2023-06-22

Citation on 2023-05-01

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

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

Corrected: Deficient, Provider has date of correction on 2023-06-22

Citation on 2023-05-01

Type: Health, Deficiency: Ensure that residents are free from significant medication errors.

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

Corrected: Deficient, Provider has date of correction on 2023-06-22

Citation on 2023-05-24

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 2023-06-28

Citation on 2023-05-24

Type: Health, Deficiency: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

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 2023-06-28

Citation on 2023-05-24

Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2023-05-24

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 2023-06-28

Citation on 2023-05-24

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 2023-06-28

Citation on 2023-05-24

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 2023-06-28

Citation on 2023-05-24

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 2023-06-28

Citation on 2023-05-24

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 2023-06-28

Citation on 2023-05-24

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

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2023-05-24

Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.

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 2023-06-28

Citation on 2023-05-24

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2023-05-24

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: 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 2023-06-28

Citation on 2023-05-24

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2023-05-24

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 2023-06-28

Citation on 2023-05-24

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 2023-06-28

Citation on 2023-05-24

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

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2023-05-24

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

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 2023-06-28

Citation on 2023-05-24

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 2023-06-28

Citation on 2022-12-07

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 2023-01-13

Citation on 2022-12-07

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 2023-01-13

Citation on 2022-12-07

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 2023-01-13

Citation on 2022-09-15

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 2022-10-15

Citation on 2022-09-15

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 2022-10-15

Citation on 2022-07-21

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

Corrected: Deficient, Provider has date of correction on 2022-08-18

Citation on 2022-07-21

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 2022-08-18

Citation on 2022-07-21

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

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 2022-08-18

Citation on 2022-07-21

Type: Health, Deficiency: Ensure that residents are free from significant medication errors.

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

Corrected: Deficient, Provider has date of correction on 2022-08-18

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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 2022-03-23

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: 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 2022-03-23

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 2022-05-04

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

Type: Health, Deficiency: Ensure that residents are free from significant medication errors.

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 2022-03-23

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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

Corrected: Deficient, Provider has date of correction on 2022-05-04

Citation on 2022-03-23

Type: Health, Deficiency: Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary 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 2022-05-04

Citation on 2022-03-23

Type: Health, Deficiency: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

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 2022-05-04

Citation on 2022-03-23

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 2022-05-04

Citation on 2022-03-23

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

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

Corrected: Deficient, Provider has date of correction on 2022-05-04

Citation on 2021-09-29

Type: Health, Deficiency: Provide appropriate colostomy, urostomy, or ileostomy 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 2021-10-29

Citation on 2020-12-30

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 2021-01-29

Citation on 2020-12-30

Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

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 2021-01-29

Citation on 2020-12-30

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: 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 2021-01-29

Citation on 2020-12-30

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

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 2021-01-29

Citation on 2020-12-30

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: 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 2021-01-29

Citation on 2020-12-30

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 2021-01-29

Citation on 2020-12-30

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 2021-01-29

Citation on 2020-12-30

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 2021-01-29

Citation on 2020-12-30

Type: Health, Deficiency: Assist a resident in gaining access to vision and hearing services.

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

Corrected: Deficient, Provider has date of correction on 2021-01-29

Citation on 2020-12-30

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 2021-01-29

Citation on 2020-12-30

Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.

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 2021-01-29

Citation on 2020-12-30

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 2021-01-29

Citation on 2020-12-30

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 2021-01-29


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-05-18

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2023-05-18

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 2023-06-28

Citation on 2023-05-18

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 2023-06-28

Citation on 2023-05-18

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 2023-06-28

Citation on 2023-05-18

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

Description: Provide properly protected cooking facilities.

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 2023-06-28

Citation on 2023-05-18

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2023-05-18

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2023-05-18

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 2023-06-28

Citation on 2023-05-18

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 2023-06-28

Citation on 2023-05-18

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 2023-06-28

Citation on 2023-05-18

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

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

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 2023-06-28

Citation on 2023-05-18

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-06-28

Citation on 2022-03-17

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 2022-05-04

Citation on 2022-03-17

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

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

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

Corrected: Deficient, Provider has date of correction on 2022-05-04

Citation on 2022-03-17

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

Description: Implement emergency and standby power systems.

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

Corrected: Deficient, Provider has date of correction on 2022-05-04

Citation on 2022-03-17

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

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

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

Corrected: Deficient, Provider has date of correction on 2022-05-04

Citation on 2022-03-17

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

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

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 2022-05-04

Citation on 2022-03-17

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

Description: Provide properly protected cooking facilities.

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 2022-03-17

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

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

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 2022-05-04

Citation on 2020-12-22

Type: Fire Safety, Tag: 0271, Version: New

Description: Have exits that are accessible at all 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 2021-01-29

Citation on 2020-12-22

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

Description: Provide properly protected cooking facilities.

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 2021-01-29

Citation on 2020-12-22

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

Description: Have an externally vented heating system.

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

Corrected: Deficient, Provider has date of correction on 2021-01-29

Citation on 2020-12-22

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 2021-01-29

Citation on 2020-12-22

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

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

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

Corrected: Deficient, Provider has date of correction on 2021-01-29