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.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0133GeneralS&S Fpotential for harm
Install a two-hour-resistant firewall separation.
- 0223GeneralS&S Epotential 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.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0711GeneralS&S Fpotential for harm
Provide a written emergency evacuation plan.
- 0920GeneralS&S Epotential for harm
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the September 25, 2023 survey of Luther Manor at Hillcrest?
This was a inspection survey of Luther Manor at Hillcrest on September 25, 2023. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Luther Manor at Hillcrest on September 25, 2023?
Yes, 11 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.