Inspection visit
Fire Safety inspection
Citations
5 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.
- 0004GeneralS&S Cno actual harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Bno actual harm
Address patient/client population and determine types of services needed.
- 0023GeneralS&S Bno actual harm
Establish policies and procedures for medical documentation.
- 0034GeneralS&S Bno actual harm
Provide a means of sharing information on occupancy/needs.
- 0039GeneralS&S Cno actual harm
Conduct testing and exercise requirements.
FAQ · About this visit
Common questions about this visit
What happened during the April 25, 2025 survey of COMPLETE CARE AT HARSTON HALL LLC?
This was a inspection survey of COMPLETE CARE AT HARSTON HALL LLC on April 25, 2025. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COMPLETE CARE AT HARSTON HALL LLC on April 25, 2025?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
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.