Inspection visit
Fire Safety inspection
Citations
21 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 Epotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0009GeneralS&S Epotential for harm
Include a process for Emergency Preparedness collaboration.
- 0018GeneralS&S Epotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0022GeneralS&S Epotential for harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Epotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Epotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Epotential for harm
Establish roles under a Waiver declared by secretary.
- 0029GeneralS&S Epotential for harm
Develop a communication plan.
- 0033GeneralS&S Epotential for harm
Establish methods for sharing information.
- 0034GeneralS&S Epotential for harm
Provide a means of sharing information on occupancy/needs.
- 0341GeneralS&S Dpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 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.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0711GeneralS&S Epotential for harm
Provide a written emergency evacuation plan.
- 0712GeneralS&S Epotential for harm
Have simulated fire drills held at unexpected times.
- 0741GeneralS&S Epotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0914GeneralS&S Epotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918GeneralS&S Epotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920GeneralS&S Dpotential for harm
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the March 7, 2025 survey of FOOTHILLS REHABILITATION CENTER?
This was a inspection survey of FOOTHILLS REHABILITATION CENTER on March 7, 2025. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FOOTHILLS REHABILITATION CENTER on March 7, 2025?
Yes, 21 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.