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.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Fpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345SeriousS&S Limmediate jeopardy
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Fpotential 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.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0914GeneralS&S Fpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923GeneralS&S Fpotential for harm
Have proper medical gas storage and administration areas.
- 0925GeneralS&S Epotential for harm
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0741GeneralS&S Fpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0761GeneralS&S Fpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0920GeneralS&S Fpotential for harm
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the February 13, 2025 survey of LEGACY AT COLLEGE HILL?
This was a inspection survey of LEGACY AT COLLEGE HILL on February 13, 2025. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LEGACY AT COLLEGE HILL on February 13, 2025?
Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide properly protected cooking facilities."
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.