A list of the most recent deficiencies for Avalon View Health and Wellness. 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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-12-14 | 2024-03-14 | 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 | 2023-12-14 | 2024-03-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-12-14 | 2024-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-14 | 2024-03-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-14 | 2024-03-14 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-12-14 | 2024-02-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-14 | 2024-01-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-14 | 2024-01-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-14 | 2024-01-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-14 | 2024-01-16 | 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 | 2023-12-14 | 2024-01-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-14 | 2024-01-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-14 | 2024-01-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-14 | 2024-01-16 | N |
| Provide or obtain dental services for each resident. | Health | 2023-12-14 | 2024-01-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-16 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-14 | 2024-01-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-12-14 | 2024-01-16 | 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 | 2023-12-14 | 2024-01-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-14 | 2024-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-14 | 2024-01-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-12-14 | 2024-01-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-14 | 2024-01-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-14 | 2024-01-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-14 | 2024-01-16 | N |
| Respond appropriately to all alleged violations. | Health | 2023-07-28 | 2023-08-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-28 | 2023-08-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-23 | 2023-05-23 | 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 | 2023-02-03 | 2023-03-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-03 | 2023-03-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-03 | 2023-03-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-02 | 2022-12-30 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-12-02 | 2022-12-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-02 | 2022-12-29 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-18 | 2022-12-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-19 | 2022-08-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-19 | 2022-08-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-08 | 2022-07-15 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-22 | 2022-06-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-22 | 2022-04-08 | 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 | 2021-12-22 | 2022-04-05 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-22 | 2022-04-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-12-22 | 2022-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-22 | 2022-04-05 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-22 | 2022-04-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-22 | 2022-04-05 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-12-22 | 2022-04-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-22 | 2022-04-05 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-22 | 2022-04-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-22 | 2022-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-22 | 2022-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-22 | 2022-04-05 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-24 | 2022-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-08 | 2022-04-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-27 | 2022-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-12 | 2022-04-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-22 | 2022-04-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-22 | 2022-04-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-22 | 2022-04-05 | 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 | 2021-12-22 | 2022-03-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-22 | 2022-03-15 | N |
| 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 | 2021-12-22 | 2022-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-22 | 2022-03-15 | N |
| 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 | 2021-12-22 | 2022-03-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-22 | 2022-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-22 | 2022-03-15 | 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 | 2021-12-22 | 2022-03-15 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-12-22 | 2022-03-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-22 | 2022-03-15 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-12-22 | 2022-03-08 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-12-22 | 2022-03-08 | 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 | 2021-12-22 | 2022-03-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-12-22 | 2022-03-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-22 | 2022-03-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-22 | 2022-03-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-22 | 2022-03-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-22 | 2022-03-08 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-22 | 2022-03-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-22 | 2022-03-08 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-22 | 2022-03-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-22 | 2022-03-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-22 | 2022-03-08 | 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 | 2021-12-22 | 2022-03-08 | N |
| 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 | 2021-12-22 | 2022-03-08 | N |
| Dispose of garbage and refuse properly. | Health | 2021-12-22 | 2022-03-08 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-22 | 2022-03-08 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-12-22 | 2022-03-08 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-12-22 | 2022-03-08 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-12-22 | 2022-03-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-22 | 2022-03-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-12-22 | 2022-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-03-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-22 | 2022-03-08 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-12-22 | 2022-03-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-22 | 2022-03-08 | N |
| Report COVID19 data to residents and families. | Health | 2021-12-22 | 2022-03-08 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-12-22 | 2022-03-08 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-12-22 | 2022-03-08 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-22 | 2022-03-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-08 | 2022-03-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-06 | 2022-03-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-06 | 2022-03-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-22 | 2022-03-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-23 | 2021-12-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-27 | 2021-12-27 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-10-27 | 2021-12-27 | Y |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-10-27 | 2021-12-27 | 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 | 2021-10-27 | 2021-12-22 | 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 | 2021-07-21 | 2021-08-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-21 | 2021-08-30 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-27 | 2021-06-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-02 | 2021-04-30 | N |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2021-03-02 | 2021-04-30 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-03-02 | 2021-04-30 | 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 | 2021-03-02 | 2021-04-30 | 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 | 2021-03-02 | 2021-04-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-02 | 2021-04-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-02 | 2021-04-30 | 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 | 2021-03-02 | 2021-04-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-02 | 2021-04-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-02 | 2021-04-30 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-02 | 2021-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-02 | 2021-04-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-02 | 2021-04-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-02 | 2021-04-30 | 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 | 2021-03-02 | 2021-04-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-03-02 | 2021-04-30 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-03-02 | 2021-04-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-03-02 | 2021-04-30 | 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 | 2021-03-02 | 2021-04-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-02 | 2021-04-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-02 | 2021-04-30 | N |
| 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 | 2021-03-02 | 2021-04-30 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-03-02 | 2021-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-02 | 2021-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-02 | 2021-04-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-02 | 2021-04-30 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-03-02 | 2021-04-30 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2021-03-02 | 2021-04-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-03-02 | 2021-04-30 | 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 | 2021-03-02 | 2021-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-03-02 | 2021-04-30 | N |
