AVAMERE REHABILITATION OF SHORELINE Nursing Home


AVAMERE REHABILITATION OF SHORELINE (CCN: 505009) is a For profit - Limited Liability company facility located in SEATTLE, WA (98155). The facility has an overall rating of 2/5, health inspection rating of 2/5, and a staffing rating of 3/5. It offers 115 certified beds and maintains an average of 63.8 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.10875 total hours per resident per day. It has been certified since January 1, 1967 and the last listed health inspection was on December 22, 2022, The facility is located in King county and provides senior and nursing home care.

AVAMERE REHABILITATION OF SHORELINE Summary


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Provider Name: AVAMERE REHABILITATION OF SHORELINE

Address: 1250 NORTHEAST 145TH STREET, SEATTLE, WA 98155

Phone: (206) 363-5856

County: King (160)

Ownership Type: For profit - Limited Liability company

Certified Beds: 115

Average Residents Per Day: 63.8 ()

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

Legal Business Name: SHORELINE OPERATIONS LLC

First Approved Date: January 1, 1967

Affiliated Entity: AVAMERE (58)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: Y

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 2 ()

Health Inspection Rating: 2 ()

QM Rating: 4 ()

Long Stay QM Rating: 4 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 3 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.66033, LPN Staff Hours Per Day: 0.8899, RN Staff Hours Per Day: 0.5584, Licensed Staff Hours Per Day: 1.4484

Total Nurse Staff Hours Per Day, per resident: 4.10875

Weekend Nurse Staff Hours: 3.45026, Weekend RN Staff Hours: 0.3267

PT Staff Hours Per Day, per resident: 0.0331

Nurse Staff Turnover: 54.8, Nurse Turnover Note:

RN Turnover: 86.7, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.2113, Case Mix LPN Hours Per Day: 0.7065, Case Mix RN Hours Per Day: 0.3316

Adjusted Nurse Aide Hours Per Day, per resident: 2.45091, Adjusted LPN Hours Per Day: 0.9295, Adjusted RN Hours Per Day: 0.6344

Total Adjusted Nurse Hours Per Day, per resident: 3.98547

Adjusted Weekend Nurse Hours Per Day, per resident: 3.34674

Health Survey Dates and Scores: Cycle 1: 2022-12-22 (Score: 96), Cycle 2: 2019-11-08 (Score: 201), Cycle 3: 2018-08-27 (Score: 242)

Total Weighted Health Score: 155.33

Reported Incidents: 10, Substantiated Complaints: 1

Infection Control Citations: 1

Fines and Penalties: Number of Fines: 6, Total Fines in Dollars: 249160.91, Payment Denials Number: 1, Total Penalties Number: 7

Location and GPS: 1250 NORTHEAST 145TH STREET,SEATTLE,WA,98155 (47.7340, -122.315)

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 2023-09-20

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 2023-10-04

Citation on 2023-07-28

Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and 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 2023-08-28

Citation on 2022-12-22

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 2023-01-20

Citation on 2022-12-22

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 2023-01-19

Citation on 2022-12-22

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 2023-01-19

Citation on 2022-12-22

Type: Health, Deficiency: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

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 2023-01-19

Citation on 2022-12-22

Type: Health, Deficiency: Assure that each resident’s assessment is updated at least once every 3 months.

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 2023-01-19

Citation on 2022-12-22

Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 2023-01-19

Citation on 2022-12-22

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 2023-01-19

Citation on 2022-12-22

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 2023-01-19

Citation on 2022-12-22

Type: Health, Deficiency: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

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 2023-01-19

Citation on 2022-12-22

Type: Health, Deficiency: Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 2023-01-19

Citation on 2022-12-22

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: 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 2023-01-19

Citation on 2022-12-22

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 2023-01-19

Citation on 2022-12-22

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 2023-02-03

Citation on 2022-12-22

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

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

Corrected: Deficient, Provider has date of correction on 2023-01-19

Citation on 2022-12-22

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 2023-01-20

Citation on 2022-12-22

Type: Health, Deficiency: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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

Corrected: Deficient, Provider has date of correction on 2023-02-07

Citation on 2022-09-19

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

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

Corrected: Deficient, Provider has date of correction on 2022-10-21

Citation on 2022-09-19

Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and 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 2022-10-21

Citation on 2022-09-19

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 2022-10-21

Citation on 2022-06-27

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

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

Corrected: Deficient, Provider has date of correction on 2022-07-20

Citation on 2019-11-08

Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 2019-11-25

Citation on 2019-11-08

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 2019-11-25

Citation on 2019-11-08

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 2019-11-25

Citation on 2019-11-08

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 2019-11-25

Citation on 2019-11-08

Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary 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 2019-11-25

Citation on 2019-11-08

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 2019-11-25

Citation on 2019-11-08

Type: Health, Deficiency: Provide or obtain dental services for 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 2019-11-25

Citation on 2019-11-08

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 2019-11-25

Citation on 2019-11-08

Type: Health, Deficiency: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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

Corrected: Deficient, Provider has date of correction on 2019-11-25

Citation on 2022-02-11

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 2022-03-04

Citation on 2022-02-11

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 2022-03-05

Citation on 2022-01-24

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

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

Corrected: Deficient, Provider has date of correction on 2022-02-11

Citation on 2021-08-09

Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and 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 2021-09-29

Citation on 2021-08-09

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 2021-09-29

Citation on 2021-08-09

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 2021-09-29

Citation on 2021-08-09

Type: Health, Deficiency: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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 2021-09-15

Citation on 2021-05-28

Type: Health, Deficiency: Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.

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 2021-07-06

Citation on 2021-05-28

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 2021-07-06

Citation on 2021-05-28

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 2021-07-06

Citation on 2018-08-27

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

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 2018-09-28

Citation on 2018-08-27

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

Severity: 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 2018-09-28


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 2022-12-20

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

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

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 2023-01-05

Citation on 2022-12-20

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

Description: Develop a communication plan.

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 2023-02-20

Citation on 2022-12-20

Type: Fire Safety, Tag: 0031, Version: New

Description: Provide emergency officials' contact information.

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 2023-02-20

Citation on 2022-12-20

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 2023-02-20

Citation on 2022-12-20

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

Description: Meet other general 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 2022-12-26

Citation on 2022-12-20

Type: Fire Safety, Tag: 0111, Version: New

Description: Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

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

Corrected: Waiver has been granted on 2023-02-10

Citation on 2022-12-20

Type: Fire Safety, Tag: 0222, Version: New

Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

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

Corrected: Deficient, Provider has date of correction on 2023-03-17

Citation on 2022-12-20

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 2023-03-08

Citation on 2022-12-20

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 2023-03-17

Citation on 2022-12-20

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 2023-01-02

Citation on 2022-12-20

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

Description: Install corridor and hallway doors that block smoke.

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

Corrected: Deficient, Provider has date of correction on 2023-01-12

Citation on 2022-12-20

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 2023-01-20

Citation on 2022-12-20

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-02-24

Citation on 2022-12-20

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 2023-03-17

Citation on 2022-12-20

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

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

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 2023-01-20

Citation on 2022-12-20

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: Waiver has been granted on 2023-03-17

Citation on 2022-12-20

Type: Fire Safety, Tag: 0926, Version: New

Description: Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

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 2023-01-24

Citation on 2019-10-31

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: 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 2019-11-28

Citation on 2019-10-31

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

Description: Provide properly protected cooking facilities.

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 2019-11-28

Citation on 2019-10-31

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

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

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

Corrected: Deficient, Provider has date of correction on 2019-11-14

Citation on 2019-10-31

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

Description: Install corridor and hallway doors that block smoke.

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

Corrected: Deficient, Provider has date of correction on 2019-11-15

Citation on 2018-10-03

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

Description: Address subsistence needs for staff and patients.

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

Corrected: Deficient, Provider has date of correction on 2018-10-26

Citation on 2018-10-03

Type: Fire Safety, Tag: 0018, Version: New

Description: Establish procedures for tracking staff and patients during an emergency.

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

Corrected: Deficient, Provider has date of correction on 2018-10-03

Citation on 2018-10-03

Type: Fire Safety, Tag: 0024, Version: New

Description: Establish policies and procedures for volunteers.

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

Corrected: Deficient, Provider has date of correction on 2018-10-26

Citation on 2018-10-03

Type: Fire Safety, Tag: 0026, Version: New

Description: Establish roles under a Waiver declared by secretary.

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

Corrected: Deficient, Provider has date of correction on 2018-10-03

Citation on 2018-10-03

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

Description: Implement emergency and standby power 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 2018-10-03

Citation on 2018-10-03

Type: Fire Safety, Tag: 0200, 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: Waiver has been granted on 2018-12-14

Citation on 2018-10-03

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 2018-10-03

Citation on 2018-10-03

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

Description: Provide properly protected cooking facilities.

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 2018-10-18

Citation on 2018-10-03

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 2018-10-26

Citation on 2018-10-03

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 2018-10-26

Citation on 2018-10-03

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: Waiver has been granted on 2018-12-14

Citation on 2018-10-03

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 2018-10-26

Citation on 2018-10-03

Type: Fire Safety, Tag: 0541, Version: New

Description: Install properly constructed and protected linen or trash chutes.

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 2018-10-05

Citation on 2018-10-03

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

Description: Provide a written emergency evacuation plan.

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 2018-10-03

Citation on 2018-10-03

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 2018-10-26

Citation on 2018-10-03

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

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

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

Corrected: Deficient, Provider has date of correction on 2018-10-26

Citation on 2018-10-03

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

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

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 2018-10-26

Citation on 2018-10-03

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 2018-10-26