Inspection visit
Fire Safety inspection
Citations
10 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.
- 0161GeneralS&S Bno actual harm
Use approved construction type or materials.
- 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.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Bno actual harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Cno actual harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0907GeneralS&S Cno actual harm
Ensure medical gas and vacuum systems have documented maintenance programs.
- 0912GeneralS&S Bno actual harm
Have power receptacles that are properly grounded.
FAQ · About this visit
Common questions about this visit
What happened during the July 25, 2024 survey of EDGEMOOR HOSPITAL?
This was a inspection survey of EDGEMOOR HOSPITAL on July 25, 2024. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EDGEMOOR HOSPITAL on July 25, 2024?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Use approved construction type or materials."
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.