Fire Safety inspection·May 9, 2025

Citations

29 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.

• 0133GeneralS&S Fpotential for harm

  Install a two-hour-resistant firewall separation.

• 0912GeneralS&S Dpotential for harm

  Have power receptacles that are properly grounded.

• 0293GeneralS&S Bno actual harm

  Have properly located and lighted "Exit" signs.

• 0041GeneralS&S Cno actual harm

  Implement emergency and standby power systems.

• 0015GeneralS&S Cno actual harm

  Address subsistence needs for staff and patients.

• 0020GeneralS&S Cno actual harm

  Establish policies and procedures including evacuation.

• 0023GeneralS&S Cno actual harm

  Establish policies and procedures for medical documentation.

• 0032GeneralS&S Cno actual harm

  Provide primary/alternate means for communication.

• 0035GeneralS&S Cno actual harm

  Provide family notifications of emergency plan.

• 0036GeneralS&S Cno actual harm

  Establish emergency prep training and testing.

• 0100GeneralS&S Fpotential for harm

  Meet other general requirements.

• 0111GeneralS&S Cno actual harm

  Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

• 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.

• 0225GeneralS&S Epotential for harm

  Have stairways and smokeproof enclosures used as exits that meet safety requirements.

• 0271GeneralS&S Fpotential for harm

  Have exits that are accessible at all times.

• 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 Cno actual harm

  Properly select, install, inspect, or maintain portable fire extinguishes.

• 0363GeneralS&S Bno actual harm

  Install corridor and hallway doors that block smoke.

• 0372GeneralS&S Fpotential for harm

  Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

• 0521GeneralS&S Fpotential for harm

  Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

• 0712GeneralS&S Bno actual 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.

• 0911GeneralS&S Epotential for harm

  Meet requirements for the installation and maintenance of electrical systems.

• 0918GeneralS&S Fpotential for harm

  Have generator or other power source capable of supplying service within 10 seconds.

• 0923GeneralS&S Cno actual harm

  Have proper medical gas storage and administration areas.

• 0006GeneralS&S Cno actual harm

  Conduct risk assessment and an All-Hazards approach.

• 0311GeneralS&S Epotential for harm

  Have an enclosure around a vertical opening shaft.

• 0324GeneralS&S Fpotential for harm

  Provide properly protected cooking facilities.