Inspection visit
Fire Safety inspection
Citations
18 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.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0004GeneralS&S Epotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Epotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Epotential for harm
Address patient/client population and determine types of services needed.
- 0020GeneralS&S Epotential for harm
Establish policies and procedures including evacuation.
- 0030GeneralS&S Epotential for harm
List the names and contact information of those in the facility.
- 0035GeneralS&S Epotential for harm
Provide family notifications of emergency plan.
- 0039GeneralS&S Epotential for harm
Conduct testing and exercise requirements.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0342GeneralS&S Dpotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0521GeneralS&S Dpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0711GeneralS&S Epotential for harm
Provide a written emergency evacuation plan.
- 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.
- 0914GeneralS&S Dpotential 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.
- 0921GeneralS&S Dpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0927GeneralS&S Epotential for harm
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
FAQ · About this visit
Common questions about this visit
What happened during the September 22, 2023 survey of THE PEAKS HEALTH & REHABILITATION?
This was a inspection survey of THE PEAKS HEALTH & REHABILITATION on September 22, 2023. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE PEAKS HEALTH & REHABILITATION on September 22, 2023?
Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install corridor and hallway doors that block smoke."
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.