Inspection visit
Fire Safety inspection
Citations
12 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 Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Dpotential for harm
Address patient/client population and determine types of services needed.
- 0026GeneralS&S Epotential for harm
Establish roles under a Waiver declared by secretary.
- 0031GeneralS&S Dpotential for harm
Provide emergency officials' contact information.
- 0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0325GeneralS&S Dpotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0351GeneralS&S Dpotential for harm
Install an approved automatic sprinkler system.
- 0761GeneralS&S Dpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0905GeneralS&S Dpotential for harm
Ensure that gas containers are correctly designed and tested, and in locations that are labeled.
- 0918GeneralS&S Dpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the April 20, 2023 survey of Mountains Community Hosp DP/SNF?
This was a inspection survey of Mountains Community Hosp DP/SNF on April 20, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Mountains Community Hosp DP/SNF on April 20, 2023?
Yes, 12 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.