A list of the most recent deficiencies for Arcadia Care Danville. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-19 | 2024-01-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-19 | 2024-01-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-30 | 2023-12-01 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-11-30 | 2023-12-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2023-12-01 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-11-30 | 2023-12-01 | Y |
| 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. | Health | 2023-11-30 | 2023-12-01 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-11-30 | 2023-12-01 | Y |
| Keep all essential equipment working safely. | Health | 2023-11-30 | 2023-12-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-24 | 2023-10-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-10 | 2023-10-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-10 | 2023-10-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-10 | 2023-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-10 | 2023-10-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-10 | 2023-10-20 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-10 | 2023-10-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-07 | 2023-09-22 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-07 | 2023-09-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-07 | 2023-09-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-23 | 2023-09-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-23 | 2023-09-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-23 | 2023-09-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-23 | 2023-09-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-23 | 2023-09-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-23 | 2023-09-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-23 | 2023-09-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-23 | 2023-09-15 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-08-23 | 2023-09-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-23 | 2023-09-15 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-08-23 | 2023-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-25 | 2023-08-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-25 | 2023-08-07 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-08 | 2023-07-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-03 | 2023-07-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-03 | 2023-07-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-03 | 2023-07-21 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-03-15 | 2023-06-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-15 | 2023-04-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-15 | 2023-04-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-15 | 2023-04-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-15 | 2023-04-13 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-03-15 | 2023-04-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-21 | 2023-04-06 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-03-21 | 2023-04-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-21 | 2023-04-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-04-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-21 | 2023-04-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-21 | 2023-04-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-21 | 2023-04-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-21 | 2023-04-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-21 | 2023-04-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-21 | 2023-03-24 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-21 | 2023-03-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-21 | 2023-03-24 | N |
| 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. | Health | 2023-03-21 | 2023-03-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-21 | 2023-03-24 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-21 | 2023-03-24 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-03-21 | 2023-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-21 | 2023-03-24 | N |
| Provide appropriate foot care. | Health | 2023-03-21 | 2023-03-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-21 | 2023-03-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-21 | 2023-03-24 | N |
| 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. | Health | 2023-03-21 | 2023-03-24 | N |
| Provide or obtain dental services for each resident. | Health | 2023-03-21 | 2023-03-24 | N |
| 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. | Health | 2023-03-21 | 2023-03-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-21 | 2023-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-21 | 2023-03-24 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-21 | 2023-03-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-21 | 2023-03-24 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-03-21 | 2023-03-24 | N |
| 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. | Health | 2022-12-13 | 2022-12-27 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-21 | 2022-10-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-21 | 2022-10-24 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-18 | 2022-08-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-18 | 2022-08-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-18 | 2022-08-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-18 | 2022-08-31 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-18 | 2022-08-31 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-08-18 | 2022-08-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-21 | 2022-08-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-21 | 2022-06-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-21 | 2022-06-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-21 | 2022-06-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-21 | 2022-06-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-26 | 2022-05-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-19 | 2022-05-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-19 | 2022-05-06 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-04-19 | 2022-05-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-22 | 2022-04-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-22 | 2022-03-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-22 | 2022-03-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-22 | 2022-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-22 | 2022-03-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-09 | 2022-02-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-09 | 2022-02-15 | Y |
| 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. | Health | 2021-12-08 | 2022-01-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-12-08 | 2022-01-19 | N |
| 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. | Health | 2021-12-08 | 2022-01-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-08 | 2022-01-19 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-12-08 | 2022-01-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-08 | 2022-01-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-08 | 2022-01-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-08 | 2022-01-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-08 | 2022-01-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-08 | 2022-01-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-08 | 2022-01-19 | N |
| 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. | Health | 2021-12-08 | 2022-01-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-12-08 | 2022-01-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-12-08 | 2022-01-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-08 | 2021-12-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-16 | 2021-09-17 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-09 | 2021-09-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-07-27 | 2021-08-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-27 | 2021-08-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-27 | 2021-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-27 | 2021-08-09 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-27 | 2021-08-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-06 | 2021-07-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-06 | 2021-07-15 | Y |
| 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. | Health | 2021-07-06 | 2021-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-06 | 2021-07-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-06 | 2021-07-15 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-07-06 | 2021-07-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-06 | 2021-07-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-06 | 2021-07-15 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-05-27 | 2021-06-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-27 | 2021-06-01 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-03-16 | 2021-04-06 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-03-16 | 2021-04-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-16 | 2021-04-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-16 | 2021-04-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-16 | 2021-04-06 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-03-16 | 2021-04-06 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-03-16 | 2021-04-06 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-10-08 | 2020-11-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-10-08 | 2020-11-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-08 | 2020-11-02 | N |
| Respond appropriately to all alleged violations. | Health | 2020-10-08 | 2020-11-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-08 | 2020-11-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-10-08 | 2020-11-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-08 | 2020-11-02 | N |
| Provide activities to meet all resident's needs. | Health | 2020-10-08 | 2020-11-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-08 | 2020-11-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-10-08 | 2020-11-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-08 | 2020-11-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-10-08 | 2020-11-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-08 | 2020-11-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-10-08 | 2020-11-02 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-10-08 | 2020-11-02 | N |
| 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. | Health | 2020-10-08 | 2020-11-02 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-10-08 | 2020-11-02 | N |
| 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. | Health | 2020-10-08 | 2020-11-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-08 | 2020-11-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-10-08 | 2020-11-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-08 | 2020-11-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-10-08 | 2020-11-02 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-10-08 | 2020-11-02 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-01 | 2020-10-25 | N |
