| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 07/30/2019 | Complaint | 4RBM | None | None | None | NoneNone | None |
| 05/28/2019 | Fire/Life/Safety | 7SYE | K0211 | D | 3 | MEANS OF EGRESS - GENERALMeans of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
| 06/18/2019 |
| 05/28/2019 | Fire/Life/Safety | 7SYE | K0291 | D | 3 | EMERGENCY LIGHTINGEmergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
| 06/18/2019 |
| 04/10/2019 | Fire/Life/Safety | Y5EO | K0345 | D | 3 | FIRE ALARM SYSTEM - TESTING AND MAINTENANCEFire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
| 05/10/2019 |
| 04/10/2019 | Fire/Life/Safety | Y5EO | K0353 | D | 3 | SPRINKLER SYSTEM - MAINTENANCE AND TESTINGSprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
| 05/10/2019 |
| 04/10/2019 | Standard | Y5EO | F0757 | D | | DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
§483.45(d)(1) In excessive dose (including duplicate drug therapy); or
§483.45(d)(2) For excessive duration; or
§483.45(d)(3) Without adequate monitoring; or
§483.45(d)(4) Without adequate indications for its use; or
§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. | 05/10/2019 |
| 04/10/2019 | Standard | Y5EO | F0759 | D | | FREE OF MEDICATION ERROR RTS 5 PRCNT OR MORE§483.45(f) Medication Errors.
The facility must ensure that its-
§483.45(f)(1) Medication error rates are not 5 percent or greater; | 05/10/2019 |
| 04/10/2019 | Standard | Y5EO | F0812 | E | | FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY§483.60(i) Food safety requirements.
The facility must -
§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.
§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. | 05/10/2019 |
| 04/10/2019 | Standard | Y5EO | N0054 | D | 3 | FOLLOW PHYSICIAN ORDERSAll physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident's medical record during that shift.
| 05/10/2019 |
| 04/10/2018 | Complaint | IHRQ | None | None | None | NoneNone | None |
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