Provider Name: BEAVERCREEK HEALTH AND REHAB
Address: 3854 PARK OVERLOOKE DRIVE, BEAVERCREEK, OH 45431
Phone: (937) 429-9655
County: Greene (290)
Ownership Type: For profit - Limited Liability company
Certified Beds: 90
Average Residents Per Day: 69.4 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: CT OHIO BEAVERCREEK, LLC
First Approved Date: November 16, 2012
Affiliated Entity: SIMCHA HYMAN & NAFTALI ZANZIPER (580)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 1 ()
Health Inspection Rating: 1 ()
QM Rating: 4 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 3 ()
Staffing Rating: 1 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.82999, LPN Staff Hours Per Day: 0.9619, RN Staff Hours Per Day: 0.4250, Licensed Staff Hours Per Day: 1.3869
Total Nurse Staff Hours Per Day, per resident: 3.21693
Weekend Nurse Staff Hours: 2.87966, Weekend RN Staff Hours: 0.2574
PT Staff Hours Per Day, per resident: 0.0475
Nurse Staff Turnover: 85.5, Nurse Turnover Note:
RN Turnover: 90.9, RN Turnover Note:
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.1517, Case Mix LPN Hours Per Day: 0.8917, Case Mix RN Hours Per Day: 0.5258
Adjusted Nurse Aide Hours Per Day, per resident: 1.73260, Adjusted LPN Hours Per Day: 0.7960, Adjusted RN Hours Per Day: 0.3045
Total Adjusted Nurse Hours Per Day, per resident: 2.84079
Adjusted Weekend Nurse Hours Per Day, per resident: 2.54295
Health Survey Dates and Scores: Cycle 1: 2023-02-01 (Score: 108), Cycle 2: 2020-01-03 (Score: 120), Cycle 3: 2018-12-11 (Score: 220)
Total Weighted Health Score: 149.00
Reported Incidents: 0, Substantiated Complaints: 33
Infection Control Citations: 6
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 9750.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 3854 PARK OVERLOOKE DRIVE,BEAVERCREEK,OH,45431 (39.7658, -84.121)
Process Date: 2024-03-01
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:
Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-01-17
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 2023-11-22
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 2023-09-06
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 2023-07-14
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 2023-07-14
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 2023-05-30
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 2023-05-30
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 2023-03-17
Type: Health, Deficiency: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 2023-03-01
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 2023-03-01
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 2023-03-01
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 2023-03-01
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-01
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-01
Type: Health, Deficiency: Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2023-02-24
Type: Health, Deficiency: Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 2023-03-01
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 2023-03-01
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 2023-03-01
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 2023-03-01
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-01
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 2023-03-01
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 2022-11-28
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 2022-11-28
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 2022-11-28
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 2022-11-28
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 2022-11-28
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 2022-09-28
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 2022-08-23
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-23
Type: Health, Deficiency: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-23
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-23
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 2022-03-25
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 2022-03-25
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 2022-03-25
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 2022-03-25
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 2020-01-24
Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-24
Type: Health, Deficiency: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 2020-01-24
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 2020-01-24
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 2020-01-24
Type: Health, Deficiency: Provide activities to meet all resident's needs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-24
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 2020-01-24
Type: Health, Deficiency: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-24
Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 2020-01-24
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 2020-01-24
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: 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 2020-01-24
Type: Health, Deficiency: Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-27
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 2022-01-27
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 2021-11-15
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 2021-11-15
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 2021-11-15
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 2021-06-04
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 2019-02-01
Type: Health, Deficiency: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-08
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 2019-02-01
Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-08
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
Type: Health, Deficiency: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
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: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
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 2019-02-01
Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is 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 2019-02-01
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
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 2019-02-08
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 2019-02-01
Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
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 2019-02-01
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 2019-02-01
Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
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 2019-02-01
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 2019-02-01
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 2019-02-08
Type: Health, Deficiency: Provide timely, quality laboratory services/tests to meet the needs of residents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-08
Type: Health, Deficiency: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
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 2019-02-01
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 2019-02-01
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 2019-02-01
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 2019-02-01
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: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-01
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:
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-01
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 2023-03-01
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-01
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 2023-03-01
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 2020-01-24
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 2020-01-24
Type: Fire Safety, Tag: 0004, Version: New
Description: Develop and maintain an Emergency Preparedness Program (EP).
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2019-01-11
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 2019-02-01