LINWOOD MEADOWS CARE CENTER Nursing Home


LINWOOD MEADOWS CARE CENTER (CCN: 555125) is a For profit - Limited Liability company facility located in VISALIA, CA (93277). The facility has an overall rating of 3/5, health inspection rating of 2/5, and a staffing rating of 3/5. It offers 98 certified beds and maintains an average of 89.9 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.00746 total hours per resident per day. It has been certified since April 16, 1980 and the last listed health inspection was on October 26, 2023, The facility is located in Tulare county and provides senior and nursing home care.

LINWOOD MEADOWS CARE CENTER Summary


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Provider Name: LINWOOD MEADOWS CARE CENTER

Address: 4444 WEST MEADOW, VISALIA, CA 93277

Phone: (559) 627-1241

County: Tulare (640)

Ownership Type: For profit - Limited Liability company

Certified Beds: 98

Average Residents Per Day: 89.9 ()

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

Legal Business Name: SNOWDROP HOLDINGS, LLC

First Approved Date: April 16, 1980

Affiliated Entity: PROVIDENCE GROUP (429)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 3 ()

Health Inspection Rating: 2 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 4 ()

Staffing Rating: 3 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.60564, LPN Staff Hours Per Day: 1.1693, RN Staff Hours Per Day: 0.2325, Licensed Staff Hours Per Day: 1.4018

Total Nurse Staff Hours Per Day, per resident: 4.00746

Weekend Nurse Staff Hours: 3.79837, Weekend RN Staff Hours: 0.2421

PT Staff Hours Per Day, per resident: 0.0594

Nurse Staff Turnover: 47.7, Nurse Turnover Note:

RN Turnover: , RN Turnover Note: 6

Admin Left Number: 1, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.9448, Case Mix LPN Hours Per Day: 0.7033, Case Mix RN Hours Per Day: 0.3369

Adjusted Nurse Aide Hours Per Day, per resident: 2.72950, Adjusted LPN Hours Per Day: 1.2268, Adjusted RN Hours Per Day: 0.2600

Total Adjusted Nurse Hours Per Day, per resident: 4.23151

Adjusted Weekend Nurse Hours Per Day, per resident: 4.01073

Health Survey Dates and Scores: Cycle 1: 2023-10-26 (Score: 104), Cycle 2: 2021-07-23 (Score: 136), Cycle 3: 2019-05-08 (Score: 96)

Total Weighted Health Score: 113.33

Reported Incidents: 3, Substantiated Complaints: 4

Infection Control Citations: 1

Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 30452.50, Payment Denials Number: 0, Total Penalties Number: 2

Location and GPS: 4444 WEST MEADOW,VISALIA,CA,93277 (36.3218, -119.340)

Process Date: 2024-03-01


Health Inspection Citations Details

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

Citation on 2023-03-30

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

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 2023-04-19

Citation on 2023-10-26

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 2023-11-16

Citation on 2023-10-26

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: 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 2023-11-16

Citation on 2023-10-26

Type: Health, Deficiency: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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 2023-11-16

Citation on 2023-10-26

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 2023-11-16

Citation on 2023-10-26

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

Corrected: Deficient, Provider has date of correction on 2023-11-16

Citation on 2023-10-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-11-16

Citation on 2023-10-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-11-16

Citation on 2023-10-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-11-16

Citation on 2023-10-26

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

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 2023-11-16

Citation on 2023-10-26

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 2023-11-16

Citation on 2023-10-26

Type: Health, Deficiency: Provide routine and 24-hour emergency dental care for each resident.

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

Corrected: Deficient, Provider has date of correction on 2023-11-16

Citation on 2023-10-26

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 2023-11-16

Citation on 2023-10-26

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 2023-11-16

Citation on 2023-10-26

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

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

Corrected: Deficient, Provider has date of correction on 2023-11-16

Citation on 2023-10-26

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 2023-11-16

Citation on 2023-10-26

Type: Health, Deficiency: Put firmly secured handrails on each side of hallways.

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 2023-11-16

Citation on 2023-01-09

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

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

Corrected: Deficient, Provider has date of correction on 2023-01-31

Citation on 2022-04-18

Type: Health, Deficiency: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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

Corrected: Deficient, Provider has date of correction on 2022-04-28

Citation on 2022-03-14

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 2022-03-28

Citation on 2021-07-23

Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 2021-09-14

Citation on 2021-07-23

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 2021-09-14

Citation on 2021-07-23

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 2021-09-14

Citation on 2021-07-23

Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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

Corrected: Deficient, Provider has date of correction on 2021-09-14

Citation on 2021-07-23

Type: Health, Deficiency: Assist a resident in gaining access to vision and hearing services.

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

Corrected: Deficient, Provider has date of correction on 2021-09-14

Citation on 2021-07-23

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

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

Corrected: Deficient, Provider has date of correction on 2021-09-14

Citation on 2021-07-23

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 2021-09-14

Citation on 2021-07-23

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 2021-09-14

Citation on 2021-07-23

Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.

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 2021-09-14

Citation on 2021-07-23

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

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

Corrected: Deficient, Provider has date of correction on 2021-09-14

Citation on 2021-07-23

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

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 2021-09-14

Citation on 2021-07-23

Type: Health, Deficiency: Dispose of garbage and refuse properly.

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 2021-09-14

Citation on 2021-07-23

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

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

Corrected: Deficient, Provider has date of correction on 2021-09-14

Citation on 2021-07-23

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

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

Corrected: Deficient, Provider has date of correction on 2021-09-14

Citation on 2021-07-23

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

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 2021-09-14

Citation on 2022-01-26

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: 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 2022-02-17

Citation on 2022-01-03

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 2022-02-21

Citation on 2021-11-01

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 2021-12-17

Citation on 2021-10-05

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

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 2021-12-03

Citation on 2019-05-08

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

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

Corrected: Deficient, Provider has date of correction on 2019-06-05

Citation on 2019-05-08

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

Corrected: Deficient, Provider has date of correction on 2019-06-05

Citation on 2019-05-08

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

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

Corrected: Deficient, Provider has date of correction on 2019-06-05

Citation on 2019-05-08

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 2019-06-05

Citation on 2019-05-08

Type: Health, Deficiency: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

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

Corrected: Deficient, Provider has date of correction on 2019-06-05

Citation on 2019-05-08

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

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

Corrected: Deficient, Provider has date of correction on 2019-06-05

Citation on 2019-05-08

Type: Health, Deficiency: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

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

Corrected: Deficient, Provider has date of correction on 2019-06-05

Citation on 2019-05-08

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

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

Corrected: Deficient, Provider has date of correction on 2019-06-05


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 2023-10-31

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

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

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 2023-11-21

Citation on 2023-10-31

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

Corrected: Deficient, Provider has date of correction on 2023-11-21

Citation on 2023-10-31

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

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

Corrected: Deficient, Provider has date of correction on 2023-11-21

Citation on 2023-10-31

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: Waiver has been granted on 2023-11-21

Citation on 2023-10-31

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 2023-11-21

Citation on 2021-07-26

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

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

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 2021-08-20

Citation on 2021-07-26

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

Description: Address patient/client population and determine types of services 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 2021-08-20

Citation on 2021-07-26

Type: Fire Safety, Tag: 0009, Version: New

Description: Include a process for Emergency Preparedness collaboration.

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 2021-08-20

Citation on 2021-07-26

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

Description: Establish procedures for tracking staff and patients during an 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 2021-08-20

Citation on 2021-07-26

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

Description: Establish policies and procedures for medical documentation.

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 2021-08-20

Citation on 2021-07-26

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

Description: Establish roles under a Waiver declared by secretary.

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 2021-08-20

Citation on 2021-07-26

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

Description: Implement emergency and standby power 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 2021-08-20

Citation on 2021-07-26

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 2021-08-20

Citation on 2021-07-26

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 2021-08-20

Citation on 2021-07-26

Type: Fire Safety, Tag: 0341, Version: New

Description: Install a fire alarm system that can be heard throughout the facility.

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 2021-08-20

Citation on 2021-07-26

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

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

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 2021-08-20

Citation on 2021-07-26

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 2021-08-20

Citation on 2021-07-26

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

Description: Provide a written emergency evacuation plan.

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 2021-08-20

Citation on 2021-07-26

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

Description: Meet requirements for the use of electrical equipment.

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 2021-08-20

Citation on 2021-07-26

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 2021-08-20

Citation on 2021-07-26

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

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 2021-08-20

Citation on 2019-06-05

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

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

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 2019-07-09

Citation on 2019-06-05

Type: Fire Safety, Tag: 0009, Version: New

Description: Include a process for Emergency Preparedness collaboration.

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 2019-07-09

Citation on 2019-06-05

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

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

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 2019-07-09

Citation on 2019-06-05

Type: Fire Safety, Tag: 0020, Version: New

Description: Establish policies and procedures including evacuation.

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 2019-07-09

Citation on 2019-06-05

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 2019-07-09

Citation on 2019-06-05

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

Description: Establish policies and procedures for volunteers.

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 2019-07-09

Citation on 2019-06-05

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

Description: Establish roles under a Waiver declared by secretary.

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 2019-07-09

Citation on 2019-06-05

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

Description: Conduct testing and exercise requirements.

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 2019-07-09

Citation on 2019-06-05

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

Description: Implement emergency and standby power 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 2019-07-09

Citation on 2019-06-05

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 2019-07-09

Citation on 2019-06-05

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

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

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 2019-07-09

Citation on 2019-06-05

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 2019-07-09

Citation on 2019-06-05

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 2019-07-09

Citation on 2019-06-05

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

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 2019-07-09