Inspection visit
Fire Safety inspection
Citations
21 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.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0020GeneralS&S Fpotential for harm
Establish policies and procedures including evacuation.
- 0111GeneralS&S Fpotential for harm
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Dpotential for 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 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.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 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.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0500GeneralS&S Fpotential for harm
Meet other general requirements that are deficient.
- 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.
- 0791GeneralS&S Fpotential for harm
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
- 0912GeneralS&S Fpotential for harm
Have power receptacles that are properly grounded.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920GeneralS&S Dpotential for harm
Ensure proper usage of power strips and extension cords.
- 0923GeneralS&S Dpotential for harm
Have proper medical gas storage and administration areas.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
FAQ · About this visit
Common questions about this visit
What happened during the March 28, 2025 survey of CHEHALEM POST ACUTE?
This was a inspection survey of CHEHALEM POST ACUTE on March 28, 2025. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CHEHALEM POST ACUTE on March 28, 2025?
Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Conduct risk assessment and an All-Hazards approach."
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.