Inspection visit
Fire Safety inspection
Citations
27 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 Cno actual harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Cno actual harm
Address patient/client population and determine types of services needed.
- 0013GeneralS&S Cno actual harm
Develop Emergency Preparedness policies and procedures.
- 0018GeneralS&S Cno actual harm
Establish procedures for tracking staff and patients during an emergency.
- 0020GeneralS&S Cno actual harm
Establish policies and procedures including evacuation.
- 0024GeneralS&S Cno actual harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Cno actual harm
Establish roles under a Waiver declared by secretary.
- 0029GeneralS&S Cno actual harm
Develop a communication plan.
- 0030GeneralS&S Cno actual harm
List the names and contact information of those in the facility.
- 0031GeneralS&S Cno actual harm
Provide emergency officials' contact information.
- 0034GeneralS&S Cno actual harm
Provide a means of sharing information on occupancy/needs.
- 0036GeneralS&S Cno actual harm
Establish emergency prep training and testing.
- 0037GeneralS&S Cno actual harm
Establish staff and initial training requirements.
- 0131GeneralS&S Cno actual harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Fpotential 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.
- 0227GeneralS&S Epotential for harm
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
- 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.
- 0341GeneralS&S Cno actual harm
Install a fire alarm system that can be heard throughout the facility.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0911GeneralS&S Epotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0914GeneralS&S Fpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
FAQ · About this visit
Common questions about this visit
What happened during the July 18, 2019 survey of MT ALVERNA HOME INC?
This was a inspection survey of MT ALVERNA HOME INC on July 18, 2019. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MT ALVERNA HOME INC on July 18, 2019?
Yes, 27 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.