AVAMERE RIVERPARK OF EUGENE Nursing Home


AVAMERE RIVERPARK OF EUGENE (CCN: 385185) is a For profit - Corporation facility located in EUGENE, OR (97401). The facility has an overall rating of 1/5, health inspection rating of 1/5, and a staffing rating of 4/5. It offers 119 certified beds and maintains an average of 87.4 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.39912 total hours per resident per day. It has been certified since August 20, 1988 and the last listed health inspection was on June 30, 2023, The facility is located in Lane county and provides senior and nursing home care.

AVAMERE RIVERPARK OF EUGENE Summary


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

Provider Name: AVAMERE RIVERPARK OF EUGENE

Address: 425 ALEXANDER LOOP, EUGENE, OR 97401

Phone: (541) 345-6199

County: Lane (190)

Ownership Type: For profit - Corporation

Certified Beds: 119

Average Residents Per Day: 87.4 ()

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

Legal Business Name: RIVERPARK OPERATIONS, LLC

First Approved Date: August 20, 1988

Affiliated Entity: AVAMERE (58)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: None

Sprinkler System Status: Yes

Overall Rating: 1 ()

Health Inspection Rating: 1 ()

QM Rating: 4 ()

Long Stay QM Rating: 3 ()

Short Stay QM Rating: 4 ()

Staffing Rating: 4 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.90764, LPN Staff Hours Per Day: 1.0842, RN Staff Hours Per Day: 0.4072, Licensed Staff Hours Per Day: 1.4914

Total Nurse Staff Hours Per Day, per resident: 4.39912

Weekend Nurse Staff Hours: 3.74234, Weekend RN Staff Hours: 0.1725

PT Staff Hours Per Day, per resident: 0.0651

Nurse Staff Turnover: 43.3, Nurse Turnover Note:

RN Turnover: 54.5, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.9825, Case Mix LPN Hours Per Day: 0.6926, Case Mix RN Hours Per Day: 0.2956

Adjusted Nurse Aide Hours Per Day, per resident: 2.98782, Adjusted LPN Hours Per Day: 1.1552, Adjusted RN Hours Per Day: 0.5191

Total Adjusted Nurse Hours Per Day, per resident: 4.66745

Adjusted Weekend Nurse Hours Per Day, per resident: 3.97060

Health Survey Dates and Scores: Cycle 1: 2023-06-30 (Score: 156), Cycle 2: 2022-05-09 (Score: 88), Cycle 3: 2019-05-09 (Score: 216)

Total Weighted Health Score: 161.33

Reported Incidents: 5, Substantiated Complaints: 18

Infection Control Citations:

Fines and Penalties: Number of Fines: 4, Total Fines in Dollars: 97305.00, Payment Denials Number: 0, Total Penalties Number: 4

Location and GPS: 425 ALEXANDER LOOP,EUGENE,OR,97401 (44.0789, -123.110)

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 2023-03-29

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 2023-04-26

Citation on 2023-03-29

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 2023-04-26

Citation on 2023-03-29

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

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

Corrected: Deficient, Provider has date of correction on 2023-04-26

Citation on 2023-03-29

Type: Health, Deficiency: Respond appropriately to all alleged violations.

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

Corrected: Deficient, Provider has date of correction on 2023-04-26

Citation on 2023-03-29

Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.

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

Corrected: Deficient, Provider has date of correction on 2023-04-26

Citation on 2023-03-29

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 2023-04-26

Citation on 2023-03-29

Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

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

Corrected: Deficient, Provider has date of correction on 2023-04-26

Citation on 2023-06-30

Type: Health, Deficiency: Ensure that residents are fully informed and understand their health status, care and treatments.

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 2023-07-25

Citation on 2023-06-30

Type: Health, Deficiency: Allow resident to participate in the development and implementation of his or her person-centered plan of 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 2023-07-25

Citation on 2023-06-30

Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.

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 2023-07-25

Citation on 2023-06-30

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 2023-07-25

Citation on 2023-06-30

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: 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 2023-07-25

Citation on 2023-06-30

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 2023-07-25

Citation on 2023-06-30

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

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

Corrected: Deficient, Provider has date of correction on 2023-07-25

Citation on 2023-06-30

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 2023-07-25

Citation on 2023-06-30

Type: Health, Deficiency: Provide medically-related social services to help each resident achieve the highest possible quality of life.

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 2023-07-25

Citation on 2023-06-30

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 2023-07-25

Citation on 2023-06-30

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

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

Corrected: Deficient, Provider has date of correction on 2023-07-25

Citation on 2023-06-30

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 2023-07-25

Citation on 2023-06-30

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

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

Corrected: Deficient, Provider has date of correction on 2023-07-25

Citation on 2023-06-30

Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.

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 2023-07-25

Citation on 2023-06-30

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 2023-07-25

Citation on 2022-08-11

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 2022-09-07

Citation on 2022-08-11

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 2022-09-07

Citation on 2022-05-09

Type: Health, Deficiency: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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

Corrected: Deficient, Provider has date of correction on 2022-05-30

Citation on 2022-05-09

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 2022-05-30

Citation on 2022-05-09

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 2022-05-30

Citation on 2022-05-09

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 2022-05-30

Citation on 2022-05-09

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

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

Corrected: Deficient, Provider has date of correction on 2022-05-30

Citation on 2022-05-09

Type: Health, Deficiency: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

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 2022-05-30

Citation on 2022-05-09

Type: Health, Deficiency: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

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 2022-05-30

Citation on 2022-05-09

Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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 2022-05-30

Citation on 2022-05-09

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

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

Corrected: Past Non-Compliance on 2022-06-22

Citation on 2022-01-24

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 2022-03-01

Citation on 2022-01-24

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 2022-03-01

Citation on 2022-01-24

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

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

Corrected: Deficient, Provider has date of correction on 2022-03-01

Citation on 2022-01-24

Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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 2022-03-01

Citation on 2022-01-24

Type: Health, Deficiency: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

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

Corrected: Past Non-Compliance on 2021-07-16

Citation on 2022-01-24

Type: Health, Deficiency: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

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 2022-03-01

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

Type: Health, Deficiency: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

Type: Health, Deficiency: Provide appropriate foot care.

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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: 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 2019-06-24

Citation on 2019-05-09

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

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 2019-08-01

Citation on 2019-05-09

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

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 2019-08-01

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

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 2019-06-24

Citation on 2019-05-09

Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

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 2019-06-24

Citation on 2019-05-09

Type: Health, Deficiency: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

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 2019-06-24

Citation on 2019-05-09

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 2019-06-24


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 2023-07-03

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

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 2023-07-25

Citation on 2023-07-03

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 2023-07-25

Citation on 2022-05-04

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 2022-05-27

Citation on 2022-05-04

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 2022-05-27

Citation on 2022-05-04

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 2022-05-27

Citation on 2022-05-04

Type: Fire Safety, Tag: 0311, Version: New

Description: Have an enclosure around a vertical opening shaft.

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 2022-05-24

Citation on 2022-05-04

Type: Fire Safety, Tag: 0741, Version: New

Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

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

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

Citation on 2022-05-04

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

Description: Meet requirements for the installation and maintenance of electrical 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 2022-05-27

Citation on 2019-05-01

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 2019-06-24

Citation on 2019-05-01

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

Description: Conduct testing and exercise requirements.

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-01

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 2019-06-24

Citation on 2019-05-01

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-01

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

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

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-01

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

Description: Have power receptacles that are properly grounded.

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

Corrected: Deficient, Provider has date of correction on 2019-06-24

Citation on 2019-05-01

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 2019-06-24