Inspection visit
Fire Safety inspection
Citations
25 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.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0009GeneralS&S Fpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0020GeneralS&S Fpotential for harm
Establish policies and procedures including evacuation.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353SeriousS&S Limmediate jeopardy
Inspect, test, and maintain automatic sprinkler systems.
- 0354SeriousS&S Limmediate jeopardy
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0362GeneralS&S Dpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0374GeneralS&S Fpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0500GeneralS&S Fpotential for harm
Meet other general requirements that are deficient.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920GeneralS&S Fpotential for harm
Ensure proper usage of power strips and extension cords.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the May 15, 2023 survey of BRIGHTON PLACE WEST?
This was a inspection survey of BRIGHTON PLACE WEST on May 15, 2023. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIGHTON PLACE WEST on May 15, 2023?
Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have simulated fire drills held at unexpected 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.