OAK HILL CENTER FOR REHABILITATION AND NURSING Nursing Home


OAK HILL CENTER FOR REHABILITATION AND NURSING (CCN: 395347) is a For profit - Corporation facility located in MIDDLETOWN, PA (17057). The facility has an overall rating of 2/5, health inspection rating of 1/5, and a staffing rating of 2/5. It offers 136 certified beds and maintains an average of 125. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.64989 total hours per resident per day. It has been certified since December 1, 1976 and the last listed health inspection was on January 26, 2023, The facility is located in Dauphin county and provides senior and nursing home care.

OAK HILL CENTER FOR REHABILITATION AND NURSING Summary


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Provider Name: OAK HILL CENTER FOR REHABILITATION AND NURSING

Address: 1020 NORTH UNION STREET, MIDDLETOWN, PA 17057

Phone: (717) 944-0451

County: Dauphin (280)

Ownership Type: For profit - Corporation

Certified Beds: 136

Average Residents Per Day: 125. ()

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

Legal Business Name: OAK HILL SNF OPERATING COMPANY LLC

First Approved Date: December 1, 1976

Affiliated Entity: ()

Retirement Community: Y, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 2 ()

Health Inspection Rating: 1 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 4 ()

Staffing Rating: 2 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.08332, LPN Staff Hours Per Day: 0.9933, RN Staff Hours Per Day: 0.5732, Licensed Staff Hours Per Day: 1.5665

Total Nurse Staff Hours Per Day, per resident: 3.64989

Weekend Nurse Staff Hours: 3.39348, Weekend RN Staff Hours: 0.4478

PT Staff Hours Per Day, per resident: 0.0473

Nurse Staff Turnover: 54.0, Nurse Turnover Note:

RN Turnover: 47.1, RN Turnover Note:

Admin Left Number: 2, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.2436, Case Mix LPN Hours Per Day: 0.7860, Case Mix RN Hours Per Day: 0.4039

Adjusted Nurse Aide Hours Per Day, per resident: 1.89166, Adjusted LPN Hours Per Day: 0.9325, Adjusted RN Hours Per Day: 0.5348

Total Adjusted Nurse Hours Per Day, per resident: 3.35053

Adjusted Weekend Nurse Hours Per Day, per resident: 3.11515

Health Survey Dates and Scores: Cycle 1: 2023-01-26 (Score: 132), Cycle 2: 2022-01-27 (Score: 108), Cycle 3: 2021-01-28 (Score: 32)

Total Weighted Health Score: 125.33

Reported Incidents: 2, Substantiated Complaints: 14

Infection Control Citations: 1

Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 25600.00, Payment Denials Number: 0, Total Penalties Number: 2

Location and GPS: 1020 NORTH UNION STREET,MIDDLETOWN,PA,17057 (40.2072, -76.735)

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 2023-08-25

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

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

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-05-10

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

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

Corrected: Deficient, Provider has date of correction on 2023-07-05

Citation on 2023-03-09

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 2023-03-17

Citation on 2023-03-09

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 2023-03-17

Citation on 2023-01-26

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 2023-02-21

Citation on 2023-01-26

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 2023-02-21

Citation on 2023-01-26

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 2023-02-21

Citation on 2023-01-26

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 2023-02-21

Citation on 2023-01-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-01-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-01-26

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 2023-02-21

Citation on 2023-01-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-01-26

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 2023-02-21

Citation on 2023-01-26

Type: Health, Deficiency: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's 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 2023-02-21

Citation on 2023-01-26

Type: Health, Deficiency: Observe each nurse aide's job performance and give regular training.

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-01-26

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 2023-02-21

Citation on 2023-01-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-01-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-01-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-01-26

Type: Health, Deficiency: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-01-26

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 2023-02-21

Citation on 2023-01-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-21

Citation on 2023-02-08

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 2023-04-09

Citation on 2023-02-08

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: 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 2023-04-09

Citation on 2022-11-22

Type: Health, Deficiency: Plan the resident's discharge to meet the resident's goals and 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 2022-12-08

Citation on 2022-05-06

Type: Health, Deficiency: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

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

Corrected: Deficient, Provider has date of correction on 2022-06-01

Citation on 2022-05-06

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 2022-06-01

Citation on 2022-01-27

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 2022-03-30

Citation on 2022-01-27

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

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

Corrected: Deficient, Provider has date of correction on 2022-03-30

Citation on 2022-01-27

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

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 2022-03-09

Citation on 2022-01-27

Type: Health, Deficiency: Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

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 2022-03-30

Citation on 2022-01-27

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 2022-03-30

Citation on 2022-01-27

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 2022-03-09

Citation on 2022-01-27

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 2022-03-09

Citation on 2022-01-27

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 2022-03-09

Citation on 2022-01-27

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 2022-03-30

Citation on 2022-01-27

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: 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 2022-03-09

Citation on 2022-01-27

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 2022-03-09

Citation on 2022-01-27

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 2022-03-09

Citation on 2022-01-27

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 2022-03-30

Citation on 2022-01-27

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 2022-03-30

Citation on 2021-01-28

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 2021-03-10

Citation on 2021-01-28

Type: Health, Deficiency: Assess the resident when there is a significant change in condition

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

Corrected: Deficient, Provider has date of correction on 2021-03-10

Citation on 2021-01-28

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 2021-03-10

Citation on 2021-01-28

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 2021-03-10

Citation on 2021-01-28

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 2021-03-10

Citation on 2021-01-28

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: 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 2021-03-10

Citation on 2021-01-28

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

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

Corrected: Deficient, Provider has date of correction on 2021-03-10


Fire Safety Citations Details

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

Citation on 2023-01-12

Type: Fire Safety, Tag: 0100, Version: New

Description: Meet other general requirements.

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

Corrected: Deficient, Provider has date of correction on 2023-02-12

Citation on 2023-01-12

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-12

Citation on 2023-01-12

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-12

Citation on 2023-01-12

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 2023-02-12

Citation on 2023-01-12

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-12

Citation on 2023-01-12

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

Description: Have power receptacles that are properly grounded.

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

Corrected: Deficient, Provider has date of correction on 2023-02-12

Citation on 2023-01-12

Type: Fire Safety, Tag: 0932, Version: New

Description: Meet other general requirements.

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

Corrected: Deficient, Provider has date of correction on 2023-02-12

Citation on 2022-01-06

Type: Fire Safety, Tag: 0100, Version: New

Description: Meet other general requirements.

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

Corrected: Deficient, Provider has date of correction on 2022-01-21

Citation on 2022-01-06

Type: Fire Safety, Tag: 0131, Version: New

Description: Meet requirements for sections of health care facilities separated by fire resistive construction.

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 2022-01-21

Citation on 2022-01-06

Type: Fire Safety, Tag: 0225, Version: New

Description: Have stairways and smokeproof enclosures used as exits that meet safety 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 2022-01-21

Citation on 2022-01-06

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: 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 2022-01-21

Citation on 2022-01-06

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

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

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

Corrected: Deficient, Provider has date of correction on 2022-01-21

Citation on 2022-01-06

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

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

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

Corrected: Deficient, Provider has date of correction on 2022-01-21

Citation on 2022-01-06

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

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

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

Corrected: Deficient, Provider has date of correction on 2022-01-21

Citation on 2022-01-06

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

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 2022-01-21

Citation on 2022-01-06

Type: Fire Safety, Tag: 0371, Version: New

Description: Have properly sized and located compartments to protect residents from smoke.

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

Corrected: Deficient, Provider has date of correction on 2022-01-21

Citation on 2022-01-06

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

Description: Have properly installed electrical wiring and gas equipment.

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

Corrected: Deficient, Provider has date of correction on 2022-01-21

Citation on 2022-01-06

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

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

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

Corrected: Deficient, Provider has date of correction on 2022-01-21

Citation on 2022-01-06

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

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

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

Corrected: Deficient, Provider has date of correction on 2022-01-21

Citation on 2020-11-05

Type: Fire Safety, Tag: 0133, Version: New

Description: Install a two-hour-resistant firewall separation.

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 2020-12-29

Citation on 2020-11-05

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 2020-12-29

Citation on 2020-11-05

Type: Fire Safety, Tag: 0225, Version: New

Description: Have stairways and smokeproof enclosures used as exits that meet safety 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 2020-12-29

Citation on 2020-11-05

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 2020-12-29

Citation on 2020-11-05

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

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

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

Corrected: Deficient, Provider has date of correction on 2020-12-29

Citation on 2020-11-05

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 2020-12-29

Citation on 2020-11-05

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

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

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 2020-12-29

Citation on 2020-11-05

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 2020-12-29

Citation on 2020-11-05

Type: Fire Safety, Tag: 0754, Version: New

Description: Provide properly sized and located linen or trash receptacles.

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

Corrected: Deficient, Provider has date of correction on 2020-12-29

Citation on 2020-11-05

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 2020-12-29

Citation on 2020-11-05

Type: Fire Safety, Tag: 0919, Version: New

Description: Meet requirements for the use of electrical equipment.

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

Corrected: Deficient, Provider has date of correction on 2020-12-29