A list of the most recent deficiencies for The Terrace at Crystal LLC. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-28 | 2023-12-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-28 | 2023-12-15 | Y |
| Have policies on smoking. | Health | 2023-11-28 | 2023-12-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-08 | 2023-12-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-08 | 2023-12-14 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-10-31 | 2023-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-31 | 2023-11-30 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-10-31 | 2023-11-30 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-10-31 | 2023-11-30 | Y |
| 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. | Health | 2023-10-31 | 2023-11-30 | 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 | 2023-09-21 | 2023-11-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-08 | 2023-11-10 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-08 | 2023-11-10 | 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 | 2023-09-08 | 2023-11-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-24 | 2023-11-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-27 | 2023-11-10 | Y |
| 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. | Health | 2023-07-27 | 2023-11-10 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-09 | 2023-10-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-21 | 2023-10-13 | Y |
| 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 | 2023-09-08 | 2023-10-13 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-05-09 | 2023-10-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-21 | 2023-10-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-08 | 2023-10-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-07-27 | 2023-10-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-24 | 2023-09-21 | Y |
| 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. | Health | 2023-08-24 | 2023-09-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-11 | 2023-09-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-11 | 2023-09-01 | Y |
| 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 | 2023-08-17 | 2023-08-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-17 | 2023-08-18 | 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 | 2023-07-17 | 2023-08-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-17 | 2023-08-18 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-09 | 2023-07-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-12 | 2023-07-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-12 | 2023-07-14 | 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 | 2023-05-12 | 2023-07-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-05-12 | 2023-07-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-05-12 | 2023-07-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-12 | 2023-07-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-12 | 2023-07-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-12 | 2023-07-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-12 | 2023-07-14 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-12 | 2023-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-12 | 2023-07-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-05-12 | 2023-07-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-12 | 2023-07-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-12 | 2023-07-14 | 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 | 2023-05-12 | 2023-07-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-12 | 2023-07-14 | N |
| 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. | Health | 2023-05-12 | 2023-07-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-12 | 2023-07-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-12 | 2023-07-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-12 | 2023-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-07-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-12 | 2023-07-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-12 | 2023-07-14 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-05-12 | 2023-07-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-12 | 2023-07-14 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-05-12 | 2023-07-14 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-05-12 | 2023-07-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-12 | 2023-07-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-12 | 2023-07-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-12 | 2023-07-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-12 | 2023-07-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-05-09 | 2023-07-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-04-25 | 2023-05-26 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-25 | 2023-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-25 | 2023-05-26 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-04-25 | 2023-05-26 | 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 | 2023-04-25 | 2023-05-26 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-18 | 2023-05-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-19 | 2023-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-02-10 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-22 | 2023-01-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-12 | 2022-11-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-29 | 2022-11-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-29 | 2022-11-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-09 | 2022-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-09 | 2022-11-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-09 | 2022-11-16 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-09 | 2022-11-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-09 | 2022-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-11-16 | 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 | 2022-08-18 | 2022-11-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-18 | 2022-11-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-18 | 2022-11-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-18 | 2022-11-16 | 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 | 2022-08-18 | 2022-11-16 | 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 | 2022-08-18 | 2022-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-18 | 2022-11-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-08-18 | 2022-11-16 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-18 | 2022-11-16 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-08-18 | 2022-11-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-18 | 2022-11-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-18 | 2022-11-16 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-08-18 | 2022-11-16 | Y |
| 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. | Health | 2022-08-18 | 2022-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-18 | 2022-11-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-18 | 2022-11-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-18 | 2022-11-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-18 | 2022-11-16 | Y |
| 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 | 2022-08-18 | 2022-09-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-18 | 2022-09-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-18 | 2022-09-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-08-18 | 2022-09-08 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-18 | 2022-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-18 | 2022-09-08 | 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 | 2022-08-18 | 2022-09-08 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-08-18 | 2022-09-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-18 | 2022-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-17 | 2022-09-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-17 | 2022-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-17 | 2022-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-17 | 2022-09-08 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2022-08-17 | 2022-09-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-09 | 2022-09-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-09 | 2022-09-03 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-08-09 | 2022-09-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-25 | 2022-08-18 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-07-25 | 2022-08-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-25 | 2022-08-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-25 | 2022-08-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-07 | 2022-07-28 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-22 | 2022-05-13 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-11 | 2022-05-02 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2022-04-11 | 2022-05-02 | Y |
| Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2022-04-11 | 2022-05-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-18 | 2022-04-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-01-20 | 2022-03-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-10 | 2022-01-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-10 | 2022-01-14 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-08 | 2021-05-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-04-08 | 2021-05-28 | 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 | 2021-04-08 | 2021-05-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-08 | 2021-05-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-08 | 2021-05-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-08 | 2021-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-08 | 2021-05-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Develop a communication plan. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-08 | 2021-05-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-06 | 2021-05-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-06 | 2021-05-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-04-06 | 2021-05-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-04-06 | 2021-05-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-06 | 2021-05-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-04-06 | 2021-05-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-06 | 2021-05-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-06 | 2021-05-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-01 | 2021-04-23 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-06 | 2021-04-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-06 | 2021-04-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-06 | 2021-04-09 | N |
