SPOKANE VETERANS HOME Nursing Home


SPOKANE VETERANS HOME (CCN: 505509) is a Government - State facility located in SPOKANE, WA (99202). The facility has an overall rating of 4/5, health inspection rating of 2/5, and a staffing rating of 5/5. It offers 100 certified beds and maintains an average of 89.5 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.33132 total hours per resident per day. It has been certified since November 21, 2001 and the last listed health inspection was on December 8, 2022, The facility is located in Spokane county and provides senior and nursing home care.

SPOKANE VETERANS HOME Summary


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Provider Name: SPOKANE VETERANS HOME

Address: 222 EAST FIFTH, SPOKANE, WA 99202

Phone: (509) 344-5770

County: Spokane (310)

Ownership Type: Government - State

Certified Beds: 100

Average Residents Per Day: 89.5 ()

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

Legal Business Name: DEPARTMENT OF VETERANS AFFAIRS SPOKANE VETERANS HOME

First Approved Date: November 21, 2001

Affiliated Entity: ()

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 4 ()

Health Inspection Rating: 2 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: (2)

Staffing Rating: 5 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.74537, LPN Staff Hours Per Day: 0.1772, RN Staff Hours Per Day: 1.4086, Licensed Staff Hours Per Day: 1.5859

Total Nurse Staff Hours Per Day, per resident: 4.33132

Weekend Nurse Staff Hours: 3.64504, Weekend RN Staff Hours: 1.1611

PT Staff Hours Per Day, per resident: 0.0528

Nurse Staff Turnover: 31.4, Nurse Turnover Note:

RN Turnover: 30.8, RN Turnover Note:

Admin Left Number: , Admin Turnover Note: 6

Case Mix Nurse Aide Hours Per Day, per resident: 1.9370, Case Mix LPN Hours Per Day: 0.6746, Case Mix RN Hours Per Day: 0.3069

Adjusted Nurse Aide Hours Per Day, per resident: 2.88734, Adjusted LPN Hours Per Day: 0.1939, Adjusted RN Hours Per Day: 1.7295

Total Adjusted Nurse Hours Per Day, per resident: 4.67776

Adjusted Weekend Nurse Hours Per Day, per resident: 3.93659

Health Survey Dates and Scores: Cycle 1: 2022-12-08 (Score: 124), Cycle 2: 2019-04-05 (Score: 92), Cycle 3: 2018-05-07 (Score: 136)

Total Weighted Health Score: 115.33

Reported Incidents: 12, Substantiated Complaints: 10

Infection Control Citations: 1

Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 59952.75, Payment Denials Number: 1, Total Penalties Number: 3

Location and GPS: 222 EAST FIFTH,SPOKANE,WA,99202 (47.6518, -117.407)

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 2024-01-23

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

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

Corrected: Deficient, Provider has plan of correction on 2024-03-01

Citation on 2024-01-23

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 plan of correction on 2024-03-01

Citation on 2023-09-12

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

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 2023-10-11

Citation on 2023-08-10

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 2023-08-15

Citation on 2023-07-18

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 2023-08-15

Citation on 2023-06-23

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 2023-08-04

Citation on 2023-06-23

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

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

Corrected: Deficient, Provider has date of correction on 2023-08-04

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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: 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 2023-01-16

Citation on 2022-12-08

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

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 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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: 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 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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

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

Corrected: Deficient, Provider has date of correction on 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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 2023-01-16

Citation on 2022-12-08

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

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 2023-01-16

Citation on 2022-12-08

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

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 2023-01-16

Citation on 2022-10-11

Type: Health, Deficiency: Keep residents' personal and medical records private and confidential.

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 2023-01-16

Citation on 2022-07-26

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 2022-08-26

Citation on 2022-06-09

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 2022-07-15

Citation on 2022-04-21

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 2022-05-20

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

Type: Health, Deficiency: Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

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

Corrected: Deficient, Provider has date of correction on 2019-05-17

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

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: 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 2019-05-17

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

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 2019-05-17

Citation on 2019-04-05

Type: Health, Deficiency: Implement a program that monitors antibiotic use.

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 2019-05-17

Citation on 2021-09-02

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 2021-10-08

Citation on 2021-06-21

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 2021-10-08

Citation on 2021-06-21

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 2021-10-08

Citation on 2021-06-21

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 2021-10-08

Citation on 2021-06-21

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 2021-10-08

Citation on 2021-06-21

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

Corrected: Deficient, Provider has date of correction on 2021-10-08

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

Type: Health, Deficiency: PASARR screening for Mental disorders or Intellectual Disabilities

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

Type: Health, Deficiency: Ensure that the resident and his/her doctor meet face-to-face at all required visits.

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

Type: Health, Deficiency: Implement a program that monitors antibiotic use.

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 2018-06-21


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 2022-11-29

Type: Fire Safety, Tag: 0023, Version: New

Description: Establish policies and procedures for medical documentation.

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 2023-01-03

Citation on 2022-11-29

Type: Fire Safety, Tag: 0223, Version: New

Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Severity: 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 2023-01-03

Citation on 2022-11-29

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: Waiver has been granted on 2023-01-03

Citation on 2022-11-29

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: Waiver has been granted on 2023-01-03

Citation on 2022-11-29

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

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

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

Corrected: Deficient, Provider has date of correction on 2023-01-03

Citation on 2019-04-08

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

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

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 2019-04-29

Citation on 2019-04-08

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 2019-04-29

Citation on 2019-04-08

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 2019-04-29

Citation on 2019-04-08

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 2019-04-29

Citation on 2018-05-07

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

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

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

Corrected: Deficient, Provider has date of correction on 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

Type: Fire Safety, Tag: 0022, Version: New

Description: Establish policies and procedures for sheltering.

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

Corrected: Deficient, Provider has date of correction on 2018-06-21

Citation on 2018-05-07

Type: Fire Safety, Tag: 0023, Version: New

Description: Establish policies and procedures for medical documentation.

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

Corrected: Deficient, Provider has date of correction on 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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 2018-06-21

Citation on 2018-05-07

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

Description: Provide emergency officials' contact information.

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

Corrected: Deficient, Provider has date of correction on 2018-06-21

Citation on 2018-05-07

Type: Fire Safety, Tag: 0032, Version: New

Description: Provide primary/alternate means for communication.

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

Corrected: Deficient, Provider has date of correction on 2018-06-21

Citation on 2018-05-07

Type: Fire Safety, Tag: 0035, Version: New

Description: Provide family notifications of emergency plan.

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

Corrected: Deficient, Provider has date of correction on 2018-06-21

Citation on 2018-05-07

Type: Fire Safety, Tag: 0037, Version: New

Description: Establish staff and initial training 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 2018-06-21

Citation on 2018-05-07

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

Description: Conduct testing and exercise 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 2018-06-21

Citation on 2018-04-27

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 2018-05-31

Citation on 2018-04-27

Type: Fire Safety, Tag: 0211, Version: New

Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.

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 2018-05-31

Citation on 2018-04-27

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

Description: Have exits that are accessible at all times.

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 2018-05-31

Citation on 2018-04-27

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 2018-04-27

Citation on 2018-04-27

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 2018-05-31

Citation on 2018-04-27

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: Waiver has been granted on 2018-06-15