Inspection visit
Fire Safety inspection
Citations
15 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Fpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0033GeneralS&S Fpotential for harm
Establish methods for sharing information.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0374GeneralS&S Fpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0711GeneralS&S Fpotential for harm
Provide a written emergency evacuation plan.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0921GeneralS&S Fpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
FAQ · About this visit
Common questions about this visit
What happened during the October 17, 2024 survey of Thomas Rest Haven?
This was a inspection survey of Thomas Rest Haven on October 17, 2024. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Thomas Rest Haven on October 17, 2024?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.