Inspection visit
Fire Safety inspection
Citations
20 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.
- 0009GeneralS&S Fpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0030GeneralS&S Fpotential for harm
List the names and contact information of those in the facility.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0100GeneralS&S Dpotential for harm
Meet other general requirements.
- 0225GeneralS&S Fpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0311GeneralS&S Dpotential for harm
Have an enclosure around a vertical opening shaft.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 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.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 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.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
FAQ · About this visit
Common questions about this visit
What happened during the September 1, 2023 survey of COVENANT SHORES HEALTH CENTER?
This was a inspection survey of COVENANT SHORES HEALTH CENTER on September 1, 2023. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COVENANT SHORES HEALTH CENTER on September 1, 2023?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Include a process for Emergency Preparedness collaboration."
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.