Inspection visit
Fire Safety inspection
Citations
11 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.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 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.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 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.
- 0907GeneralS&S Fpotential for harm
Ensure medical gas and vacuum systems have documented maintenance programs.
- 0909GeneralS&S Fpotential for harm
Ensure gas and vacuum piping is labeled.
- 0912GeneralS&S Fpotential for harm
Have power receptacles that are properly grounded.
- 0918GeneralS&S Dpotential 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 December 4, 2025 survey of EDGEMOOR HOSPITAL?
This was a inspection survey of EDGEMOOR HOSPITAL on December 4, 2025. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EDGEMOOR HOSPITAL on December 4, 2025?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Properly select, install, inspect, or maintain portable fire extinguishes."
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.