NORMANDY TERRACE NURSING & REHABILITATION CENTER Nursing Home


NORMANDY TERRACE NURSING & REHABILITATION CENTER (CCN: 675823) is a For profit - Corporation facility located in SAN ANTONIO, TX (78220). The facility has an overall rating of 2/5, health inspection rating of 2/5, and a staffing rating of 2/5. It offers 320 certified beds and maintains an average of 106. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.20168 total hours per resident per day. It has been certified since March 16, 2000 and the last listed health inspection was on April 6, 2023, The facility is located in Bexar county and provides senior and nursing home care.

NORMANDY TERRACE NURSING & REHABILITATION CENTER Summary


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Provider Name: NORMANDY TERRACE NURSING & REHABILITATION CENTER

Address: 841 RICE RD, SAN ANTONIO, TX 78220

Phone: (210) 648-0101

County: Bexar (130)

Ownership Type: For profit - Corporation

Certified Beds: 320

Average Residents Per Day: 106. ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: WEST WHARTON COUNTY HOSPITAL DISTRICT

First Approved Date: March 16, 2000

Affiliated Entity: CREATIVE SOLUTIONS IN HEALTHCARE (169)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 2 ()

Health Inspection Rating: 2 ()

QM Rating: 3 ()

Long Stay QM Rating: 3 ()

Short Stay QM Rating: (2)

Staffing Rating: 2 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.68116, LPN Staff Hours Per Day: 0.9932, RN Staff Hours Per Day: 0.5272, Licensed Staff Hours Per Day: 1.5205

Total Nurse Staff Hours Per Day, per resident: 3.20168

Weekend Nurse Staff Hours: 2.78269, Weekend RN Staff Hours: 0.4465

PT Staff Hours Per Day, per resident: 0.0481

Nurse Staff Turnover: , Nurse Turnover Note: 6

RN Turnover: , RN Turnover Note: 6

Admin Left Number: , Admin Turnover Note: 6

Case Mix Nurse Aide Hours Per Day, per resident: 1.9436, Case Mix LPN Hours Per Day: 0.7033, Case Mix RN Hours Per Day: 0.3467

Adjusted Nurse Aide Hours Per Day, per resident: 1.76217, Adjusted LPN Hours Per Day: 1.0422, Adjusted RN Hours Per Day: 0.5729

Total Adjusted Nurse Hours Per Day, per resident: 3.37104

Adjusted Weekend Nurse Hours Per Day, per resident: 2.92988

Health Survey Dates and Scores: Cycle 1: 2023-04-06 (Score: 40), Cycle 2: 2022-02-18 (Score: 172), Cycle 3: 2021-03-26 (Score: 172)

Total Weighted Health Score: 106.00

Reported Incidents: 6, Substantiated Complaints: 22

Infection Control Citations: 15

Fines and Penalties: Number of Fines: 7, Total Fines in Dollars: 64663.14, Payment Denials Number: 1, Total Penalties Number: 8

Location and GPS: 841 RICE RD,SAN ANTONIO,TX,78220 (29.4091, -98.404)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-04-06

Type: Health, Deficiency: Honor the resident's right to organize and participate in resident/family groups in the facility.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-05

Citation on 2023-04-06

Type: Health, Deficiency: 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.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-05

Citation on 2023-04-06

Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-05

Citation on 2023-04-06

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-05

Citation on 2023-04-06

Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-05

Citation on 2022-08-17

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-09-14

Citation on 2023-01-09

Type: Health, Deficiency: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-08

Citation on 2023-01-09

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-08

Citation on 2023-01-09

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-08

Citation on 2023-01-09

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-02-08

Citation on 2022-11-04

Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-11-05

Citation on 2022-07-07

Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-01

Citation on 2022-06-09

Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-30

Citation on 2022-02-18

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: 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.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Respond appropriately to all alleged violations.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Provide activities to meet all resident's needs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: 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.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Ensure that residents are free from significant medication errors.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Dispose of garbage and refuse properly.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Provide or get specialized rehabilitative services as required for a resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Keep all essential equipment working safely.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Make sure that a working call system is available in each resident's bathroom and bathing area.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-18

Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-01

Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-14

Citation on 2022-02-01

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-14

Citation on 2022-02-01

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-14

Citation on 2022-02-01

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-14

Citation on 2022-02-01

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-14

Citation on 2021-12-09

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-30

Citation on 2021-12-09

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-30

Citation on 2021-12-03

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-30

Citation on 2021-12-03

Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-30

Citation on 2021-12-03

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-30

Citation on 2021-11-03

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-30

Citation on 2021-09-17

Type: Health, Deficiency: 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.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-29

Citation on 2021-09-17

Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-29

Citation on 2021-09-17

Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-29

Citation on 2021-09-17

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-29

Citation on 2021-09-17

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Past Non-Compliance on 2021-07-08

Citation on 2021-09-17

Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-29

Citation on 2021-07-27

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-08-25

Citation on 2021-03-26

Type: Health, Deficiency: Assure the security of all personal funds of residents deposited with the facility.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-26

Type: Health, Deficiency: Provide or obtain dental services for each resident.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-26

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-26

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-26

Type: Health, Deficiency: Make sure that a working call system is available in each resident's bathroom and bathing area.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-26

Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-05-05

Type: Fire Safety, Tag: 0111, Version: New

Description: Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0346, Version: New

Description: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Waiver has been granted on 2023-05-06

Citation on 2023-05-05

Type: Fire Safety, Tag: 0741, Version: New

Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0916, Version: New

Description: Have a battery powered remote alarm panel in a location accessible by operating personnel.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0917, Version: New

Description: Ensure electrical receptacles or cover plates have distinctive color or marking.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2023-05-05

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-05

Citation on 2022-02-24

Type: Fire Safety, Tag: 0341, Version: New

Description: Install a fire alarm system that can be heard throughout the facility.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-24

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-02-25

Citation on 2022-02-24

Type: Fire Safety, Tag: 0761, Version: New

Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-02-24

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2021-03-24

Type: Fire Safety, Tag: 0222, Version: New

Description: 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.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-24

Type: Fire Safety, Tag: 0223, Version: New

Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-24

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-24

Type: Fire Safety, Tag: 0331, Version: New

Description: Construct fire resistant interior walls.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-24

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-24

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-24

Type: Fire Safety, Tag: 0374, Version: New

Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26

Citation on 2021-03-24

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-26