Pinnacle Health Facilities Xvi, L.p.
Survey Date: Tuesday, December 3, 2013
Survey Type: Fire Safety
Deficiency: K0076 (Proper medical gas storage and administration areas.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, January 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, December 3, 2013
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, January 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, December 3, 2013
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, January 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, December 3, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, January 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, December 3, 2013
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, January 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, December 3, 2013
Survey Type: Fire Safety
Deficiency: K0017 (Corridors that are separated from use areas by walls constructed to limit the passage of smoke.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, January 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, December 3, 2013
Survey Type: Fire Safety
Deficiency: K0046 (Emergency lighting that can last at least 1 1/2 hours.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, January 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, December 3, 2013
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, January 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 7, 2013
Survey Type: Health
Deficiency: F0278 (Ensure each resident receives an accurate assessment by a qualified health professional.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, December 14, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 7, 2013
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, December 14, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 7, 2013
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, December 14, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0047 (Properly located and lighted "Exit" signs.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0046 (Emergency lighting that can last at least 1 1/2 hours.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0073 (Restrictions on the use of highly flammable decorations.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0017 (Corridors that are separated from use areas by walls constructed to limit the passage of smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, December 12, 2012
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0363 (Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nut)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0428 (At least once a month, have a licensed pharmacist review each resident's medication (s) and report a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0312 (Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, November 15, 2012
Survey Type: Health
Deficiency: F0281 (Ensure services provided by the nursing facility meet professional standards of quality.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 13, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, October 18, 2011
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, November 28, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, October 18, 2011
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 18, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, October 18, 2011
Survey Type: Fire Safety
Deficiency: K0076 (Proper medical gas storage and administration areas.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 15, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, October 18, 2011
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 18, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, October 5, 2011
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 25, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, October 5, 2011
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, October 5, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, October 5, 2011
Survey Type: Health
Deficiency: F0469 (Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, October 19, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, October 5, 2011
Survey Type: Health
Deficiency: F0244 (Listen to the resident groups and act on their complaints and suggestions that affect resident care )
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, October 28, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)