Inspection visit
Fire Safety inspection
Citations
19 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).
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0030GeneralS&S Fpotential for harm
List the names and contact information of those in the facility.
- 0161GeneralS&S Epotential for harm
Use approved construction type or materials.
- 0211GeneralS&S Dpotential 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.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 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.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0711GeneralS&S Fpotential for harm
Provide a written emergency evacuation plan.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0753GeneralS&S Fpotential for harm
Have restrictions on the use of highly flammable decorations.
- 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 December 21, 2021 survey of ELMHAVEN EAST?
This was a inspection survey of ELMHAVEN EAST on December 21, 2021. The surveyor cited 19 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELMHAVEN EAST on December 21, 2021?
Yes, 19 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.