Inspection visit
Fire Safety inspection
Citations
14 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.
- 0132GeneralS&S Dpotential for harm
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
- 0222GeneralS&S Dpotential 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.
- 0223GeneralS&S Dpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential 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.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0531GeneralS&S Epotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0911GeneralS&S Fpotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0912GeneralS&S Dpotential for harm
Have power receptacles that are properly grounded.
FAQ · About this visit
Common questions about this visit
What happened during the November 30, 2023 survey of Complete Care at Nazareth LLC?
This was a inspection survey of Complete Care at Nazareth LLC on November 30, 2023. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Complete Care at Nazareth LLC on November 30, 2023?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive constructio..."
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.