Inspection visit
Fire Safety inspection
Citations
33 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 Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Fpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0374GeneralS&S Dpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0525GeneralS&S Dpotential for harm
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
- 0711GeneralS&S Fpotential for harm
Provide a written emergency evacuation plan.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920GeneralS&S Fpotential 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.
- 0926GeneralS&S Fpotential for harm
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0020GeneralS&S Fpotential for harm
Establish policies and procedures including evacuation.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 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.
- 0033GeneralS&S Fpotential for harm
Establish methods for sharing information.
- 0034GeneralS&S Fpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0100GeneralS&S Fpotential for harm
Meet other general requirements.
- 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.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
FAQ · About this visit
Common questions about this visit
What happened during the May 9, 2025 survey of ELISEO?
This was a inspection survey of ELISEO on May 9, 2025. The surveyor cited 33 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELISEO on May 9, 2025?
Yes, 33 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.