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.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
- 0036GeneralS&S Cno actual harm
Establish emergency prep training and testing.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0291GeneralS&S Cno actual harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
- 0029GeneralS&S Cno actual harm
Develop a communication plan.
- 0004GeneralS&S Cno actual harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0013GeneralS&S Cno actual harm
Develop Emergency Preparedness policies and procedures.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0361GeneralS&S Epotential for harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0531GeneralS&S Fpotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0761GeneralS&S Cno actual harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0918GeneralS&S Fpotential 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 April 21, 2023 survey of BETHEL MANOR?
This was a inspection survey of BETHEL MANOR on April 21, 2023. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BETHEL MANOR on April 21, 2023?
Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have exits that are accessible at all times."
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.