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.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0030GeneralS&S Fpotential for harm
List the names and contact information of those in the facility.
- 0031GeneralS&S Fpotential for harm
Provide emergency officials' contact information.
- 0222GeneralS&S Fpotential 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.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0522GeneralS&S Dpotential for harm
Have an externally vented heating system.
- 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.
- 0920GeneralS&S Dpotential 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.
FAQ · About this visit
Common questions about this visit
What happened during the March 25, 2025 survey of STAFHOLT HEALTH AND REHABILITATION OF CASCADIA?
This was a inspection survey of STAFHOLT HEALTH AND REHABILITATION OF CASCADIA on March 25, 2025. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at STAFHOLT HEALTH AND REHABILITATION OF CASCADIA on March 25, 2025?
Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Inspect, test, and maintain automatic sprinkler systems."
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.