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.
- 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.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0020GeneralS&S Fpotential for harm
Establish policies and procedures including evacuation.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0222GeneralS&S Cno actual 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.
- 0223GeneralS&S Fpotential 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.
- 0232GeneralS&S Dpotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 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.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0761GeneralS&S Fpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0916GeneralS&S Dpotential for harm
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
FAQ · About this visit
Common questions about this visit
What happened during the March 29, 2023 survey of GORHAM HOUSE?
This was a inspection survey of GORHAM HOUSE on March 29, 2023. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GORHAM HOUSE on March 29, 2023?
Yes, 25 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.