Inspection visit
Fire Safety inspection
Citations
17 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.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0200GeneralS&S Dpotential for harm
Meet other general requirements.
- 0222GeneralS&S Epotential for harm
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.
- 0291GeneralS&S Epotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712GeneralS&S Epotential for harm
Have simulated fire drills held at unexpected times.
- 0761GeneralS&S Epotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0781GeneralS&S Epotential for harm
Have restrictions on the use of portable space heaters.
- 0901GeneralS&S Epotential for harm
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
- 0911GeneralS&S Epotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
FAQ · About this visit
Common questions about this visit
What happened during the October 15, 2024 survey of OUR LADY OF PEACE NURSING CARE RESIDENCE?
This was a inspection survey of OUR LADY OF PEACE NURSING CARE RESIDENCE on October 15, 2024. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at OUR LADY OF PEACE NURSING CARE RESIDENCE on October 15, 2024?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguish..."
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.