Inspection visit
Fire Safety inspection
Citations
24 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.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 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.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0223GeneralS&S Epotential 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.
- 0226GeneralS&S Epotential for harm
Have horizontal exits used in accordance with safety requirements.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0372GeneralS&S Epotential 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.
- 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.
- 0781GeneralS&S Epotential for harm
Have restrictions on the use of portable space heaters.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920GeneralS&S Epotential for harm
Ensure proper usage of power strips and extension cords.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
FAQ · About this visit
Common questions about this visit
What happened during the January 26, 2024 survey of Villa at Willow Place?
This was a inspection survey of Villa at Willow Place on January 26, 2024. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Villa at Willow Place on January 26, 2024?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish procedures for tracking staff and patients during an emergency."
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.