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).
- 0006GeneralS&S Cno actual harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Cno actual harm
Address patient/client population and determine types of services needed.
- 0015GeneralS&S Cno actual harm
Address subsistence needs for staff and patients.
- 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.
- 0022GeneralS&S Cno actual harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Cno actual harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Cno actual harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Cno actual harm
Establish roles under a Waiver declared by secretary.
- 0030GeneralS&S Cno actual harm
List the names and contact information of those in the facility.
- 0032GeneralS&S Cno actual harm
Provide primary/alternate means for communication.
- 0033GeneralS&S Cno actual harm
Establish methods for sharing information.
- 0034GeneralS&S Cno actual harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Cno actual harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Cno actual harm
Establish emergency prep training and testing.
- 0037GeneralS&S Cno actual harm
Establish staff and initial training requirements.
- 0039GeneralS&S Cno actual harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Cno actual harm
Implement emergency and standby power systems.
- 0100GeneralS&S Dpotential for harm
Meet other general requirements.
- 0362GeneralS&S Dpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0741GeneralS&S Dpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 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.
- 0920GeneralS&S Dpotential for harm
Ensure proper usage of power strips and extension cords.
- 0923GeneralS&S Dpotential for harm
Have proper medical gas storage and administration areas.
- 0919GeneralS&S Dpotential for harm
Meet requirements for the use of electrical equipment.
FAQ · About this visit
Common questions about this visit
What happened during the May 4, 2018 survey of THALIA GARDENS REHABILITATION AND NURSING?
This was a inspection survey of THALIA GARDENS REHABILITATION AND NURSING on May 4, 2018. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THALIA GARDENS REHABILITATION AND NURSING on May 4, 2018?
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.