Inspection visit
Fire Safety inspection
Citations
26 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.
- 0007GeneralS&S Epotential for harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Epotential for harm
Include a process for Emergency Preparedness collaboration.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0018GeneralS&S Epotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0024GeneralS&S Epotential for harm
Establish policies and procedures for volunteers.
- 0025GeneralS&S Epotential for harm
Create arrangements with other facilities to receive patients.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Epotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Epotential for harm
Conduct testing and exercise requirements.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0281GeneralS&S Epotential for harm
Install proper backup exit lighting.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0293GeneralS&S Fpotential for harm
Have properly located and lighted "Exit" signs.
- 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 Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 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.
- 0914GeneralS&S Fpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
- 0004GeneralS&S Epotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
FAQ · About this visit
Common questions about this visit
What happened during the August 15, 2025 survey of BELVEDERE CENTER, GENESIS HEALTHCARE, THE?
This was a inspection survey of BELVEDERE CENTER, GENESIS HEALTHCARE, THE on August 15, 2025. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BELVEDERE CENTER, GENESIS HEALTHCARE, THE on August 15, 2025?
Yes, 26 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.