Inspection visit
Fire Safety inspection
Citations
13 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 Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0020GeneralS&S Dpotential for harm
Establish policies and procedures including evacuation.
- 0041GeneralS&S Epotential for harm
Implement emergency and standby power systems.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0223GeneralS&S Dpotential 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.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0232GeneralS&S Epotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 0241GeneralS&S Epotential for harm
Have correct number of accessible exits for each story.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0712GeneralS&S Dpotential for harm
Have simulated fire drills held at unexpected times.
- 0918GeneralS&S Epotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the December 2, 2022 survey of Pope Nursing Home?
This was a inspection survey of Pope Nursing Home on December 2, 2022. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Pope Nursing Home on December 2, 2022?
Yes, 13 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.