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.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0020GeneralS&S Epotential for harm
Establish policies and procedures including evacuation.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0100GeneralS&S Epotential for harm
Meet other general requirements.
- 0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
- 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.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Fpotential 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 Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0711SeriousS&S Kimmediate jeopardy
Provide a written emergency evacuation plan.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0741GeneralS&S Epotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0919GeneralS&S Epotential for harm
Meet requirements for the use of electrical equipment.
- 0920GeneralS&S Epotential for harm
Ensure proper usage of power strips and extension cords.
- 0921GeneralS&S Fpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
- 0926GeneralS&S Epotential for harm
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
FAQ · About this visit
Common questions about this visit
What happened during the November 27, 2024 survey of BELOVED HEALTH AND REHABILITATION CENTER?
This was a inspection survey of BELOVED HEALTH AND REHABILITATION CENTER on November 27, 2024. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BELOVED HEALTH AND REHABILITATION CENTER on November 27, 2024?
Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop Emergency Preparedness policies and procedures."
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.