Federal inspection record · CMS data as of October 1, 2026

Ballard Center

820 Northwest 95th Street, Seattle, WA · (206) 782-0100

CMS overall rating

1 of 5

Compare with a nearby home →
Certified beds
142
Residents per day
104
Ownership
For-Profit
Chain
Genesis Healthcare
Medicare / Medicaid
Medicare + Medicaid
Certified since
January 1, 1967

1

How this home got 1 star

The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.

  1. Health inspections

    starting point

    Everything starts from what state inspectors found on site. This is a ranking against other homes in Washington.

  2. Staffing

    no change

    Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.

  3. Quality measures

    no change

    Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.

  4. Overall

    1 of 5

    Matches the rating CMS publishes on Care Compare.

2

Where it sits among Washington homes

Ballard Center carries 175 inspection points. That is fewer than 16% of Washington's 192 rated homes.

5★4★3★2★1★+6 homes above 393.505102550100200inspection points → fewer is better on the leftThis home · 175 pts · 1★

Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Washington: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.

  • 5★ 0–31 pts
  • 4★ 31–69 pts
  • 3★ 69–100 pts
  • 2★ 100–167 pts
  • 1★ over 167 pts

Bars show every rated home in Washington by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.

3

What inspectors found

77 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.

One resident or a fewA patternWidespread

Immediate jeopardyResidents at risk of serious injury or death

J 0 50 pts
K 0 100 pts
L 0 150 pts

Actual harmA resident was hurt

G 0 20 pts
H 0 35 pts
I 0 45 pts

Potential for harmNo one was hurt, but could have been

D 51 4 pts
E 24 8 pts
F 1 16 pts

Minimal harmPaperwork-level problems

A 0 0 pts
B 0 0 pts
C 1 0 pts

Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.

Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.

No citation on record at the harm or immediate-jeopardy level.

Everything else, by area of care

Resident Assessment and Care Planning25E
  1. E

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

    April 16, 2026 · Complaint · F636 · Corrected May 9, 2026

  2. E

    Assess the resident when there is a significant change in condition

    April 16, 2026 · Standard · F637 · Corrected May 9, 2026

  3. E

    Assure that each resident’s assessment is updated at least once every 3 months.

    April 16, 2026 · Standard · F638 · Corrected May 9, 2026

  4. E

    Ensure each resident receives an accurate assessment.

    April 16, 2026 · Complaint · F641 · Corrected May 9, 2026

  5. D

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

    April 16, 2026 · Standard · F640 · Corrected May 9, 2026

  6. D

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

    April 16, 2026 · Standard · F644 · Corrected May 9, 2026

  7. D

    PASARR screening for Mental disorders or Intellectual Disabilities

    April 16, 2026 · Standard · F645 · Corrected May 9, 2026

  8. D

    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

    April 16, 2026 · Standard · F646 · Corrected May 9, 2026

  9. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    April 16, 2026 · Standard · F656 · Corrected May 9, 2026

  10. D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    April 16, 2026 · Complaint · F657 · Corrected May 9, 2026

  11. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    December 31, 2025 · Complaint · F656 · Corrected January 26, 2026

  12. D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    March 28, 2025 · Complaint · F657 · Corrected April 4, 2025

  13. D

    Ensure each resident receives an accurate assessment.

    January 8, 2025 · Standard · F641 · Corrected February 7, 2025

  14. D

    PASARR screening for Mental disorders or Intellectual Disabilities

    January 8, 2025 · Standard · F645 · Corrected February 7, 2025

  15. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    January 8, 2025 · Complaint · F656 · Corrected February 7, 2025

  16. D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    January 8, 2025 · Standard · F657 · Corrected February 7, 2025

  17. D

    Ensure services provided by the nursing facility meet professional standards of quality.

    January 8, 2025 · Standard · F658 · Corrected February 7, 2025

  18. D

    Plan the resident's discharge to meet the resident's goals and needs.

    January 8, 2025 · Standard · F660 · Corrected February 7, 2025

  19. D

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

    September 13, 2023 · Standard · F636 · Corrected October 25, 2023

  20. D

    Assess the resident when there is a significant change in condition

    September 13, 2023 · Standard · F637 · Corrected October 25, 2023

  21. D

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

    September 13, 2023 · Standard · F640 · Corrected October 25, 2023

  22. D

    Ensure each resident receives an accurate assessment.

    September 13, 2023 · Standard · F641 · Corrected October 25, 2023

  23. D

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    September 13, 2023 · Standard · F655 · Corrected October 25, 2023

  24. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    September 13, 2023 · Standard · F656 · Corrected October 25, 2023

  25. D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    September 13, 2023 · Standard · F657 · Corrected October 25, 2023

Quality of Life and Care18E
  1. D

    Assist a resident in gaining access to vision and hearing services.

    July 23, 2026 · Complaint · F685 · Corrected August 7, 2026

  2. E

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    April 16, 2026 · Standard · F689 · Corrected May 9, 2026

  3. E

    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

    April 16, 2026 · Standard · F700 · Corrected May 9, 2026

  4. D

    Provide activities to meet all resident's needs.

    April 16, 2026 · Standard · F679 · Corrected May 9, 2026

  5. D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    April 16, 2026 · Standard · F684 · Corrected May 9, 2026

  6. D

    Provide safe and appropriate respiratory care for a resident when needed.

    April 16, 2026 · Standard · F695 · Corrected May 9, 2026

  7. D

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    April 16, 2026 · Standard · F698 · Corrected May 9, 2026

  8. E

    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

    November 14, 2025 · Complaint · F678 · Corrected December 14, 2025

  9. D

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    January 8, 2025 · Standard · F677 · Corrected February 7, 2025

  10. D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    January 8, 2025 · Complaint · F684 · Corrected February 7, 2025

  11. D

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

    January 8, 2025 · Standard · F688 · Corrected February 7, 2025

  12. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    January 8, 2025 · Standard · F689 · Corrected February 7, 2025

  13. D

    Provide safe and appropriate respiratory care for a resident when needed.

    January 8, 2025 · Standard · F695 · Corrected February 7, 2025

  14. D

    Provide or obtain dental services for each resident.

    February 28, 2024 · Complaint · F791 · Corrected April 4, 2024

  15. D

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    September 13, 2023 · Standard · F677 · Corrected October 25, 2023

  16. D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    September 13, 2023 · Standard · F684 · Corrected October 25, 2023

  17. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    September 13, 2023 · Standard · F689 · Corrected October 25, 2023

  18. D

    Provide enough food/fluids to maintain a resident's health.

    September 13, 2023 · Standard · F692 · Corrected October 25, 2023

Resident Rights9E
  1. D

    Ensure that residents are fully informed and understand their health status, care and treatments.

    July 23, 2026 · Complaint · F552 · Corrected August 7, 2026

  2. E

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

    June 29, 2026 · Complaint · F628 · Corrected July 13, 2026

  3. D

    Allow residents to self-administer drugs if determined clinically appropriate.

    April 16, 2026 · Standard · F554 · Corrected May 9, 2026

  4. E

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

    November 14, 2025 · Complaint · F628 · Corrected December 14, 2025

  5. D

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    January 8, 2025 · Standard · F585 · Corrected February 7, 2025

  6. E

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    September 13, 2023 · Standard · F585 · Corrected October 25, 2023

  7. D

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    September 13, 2023 · Standard · F584 · Corrected October 25, 2023

  8. D

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    September 13, 2023 · Standard · F623 · Corrected October 25, 2023

  9. D

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

    September 13, 2023 · Standard · F625 · Corrected October 25, 2023

Nutrition and Dietary6F
  1. D

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    April 16, 2026 · Standard · F812 · Corrected May 9, 2026

  2. E

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

    January 8, 2025 · Standard · F803 · Corrected February 7, 2025

  3. E

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    January 6, 2025 · Complaint · F804 · Corrected February 3, 2025

  4. D

    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

    October 23, 2023 · Complaint · F806 · Corrected October 28, 2023

  5. F

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

    September 13, 2023 · Standard · F801 · Corrected October 25, 2023

  6. E

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    September 13, 2023 · Standard · F804 · Corrected October 25, 2023

Freedom from Abuse, Neglect, and Exploitation6E
  1. E

    Respond appropriately to all alleged violations.

    March 25, 2026 · Complaint · F610 · Corrected April 11, 2026

  2. D

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    March 25, 2026 · Complaint · F609 · Corrected April 11, 2026

  3. D

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    May 8, 2025 · Complaint · F609 · Corrected May 12, 2025

  4. D

    Respond appropriately to all alleged violations.

    March 28, 2025 · Complaint · F610 · Corrected April 4, 2025

  5. E

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    January 8, 2025 · Standard · F607 · Corrected February 7, 2025

  6. D

    Respond appropriately to all alleged violations.

    January 8, 2025 · Standard · F610 · Corrected February 7, 2025

Pharmacy Service4E
  1. E

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    April 16, 2026 · Standard · F755 · Corrected May 9, 2026

  2. E

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

    April 16, 2026 · Standard · F757 · Corrected May 9, 2026

  3. E

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    April 16, 2026 · Standard · F761 · Corrected May 9, 2026

  4. E

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    January 8, 2025 · Standard · F761 · Corrected February 7, 2025

Infection Control4E
  1. E

    Provide and implement an infection prevention and control program.

    April 16, 2026 · Complaint · F880 · Corrected May 9, 2026

  2. D

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

    April 16, 2026 · Complaint · F883 · Corrected May 9, 2026

  3. D

    Provide and implement an infection prevention and control program.

    March 28, 2025 · Complaint · F880 · Corrected April 4, 2025

  4. E

    Provide and implement an infection prevention and control program.

    January 8, 2025 · Standard · F880 · Corrected February 7, 2025

Nursing and Physician Services2E
  1. E

    Post nurse staffing information every day.

    April 16, 2026 · Standard · F732 · Corrected May 9, 2026

  2. E

    Observe each nurse aide's job performance and give regular training.

    January 8, 2025 · Standard · F730 · Corrected February 7, 2025

Environmental2E
  1. D

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

    April 21, 2025 · Complaint · F925 · Corrected May 9, 2025

  2. E

    Keep all essential equipment working safely.

    January 6, 2025 · Complaint · F908 · Corrected February 3, 2025

Administration1C
  1. C

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

    January 8, 2025 · Standard · F838 · Corrected February 7, 2025

Inspection history

  1. 2026-04-16

    32 health deficiencies · 40 fire-safety deficiencies

    Top issue: Resident Assessment and Care Planning (11 deficiencies)

  2. 2025-01-08

    26 health deficiencies · 29 fire-safety deficiencies

    Top issue: Resident Assessment and Care Planning (7 deficiencies)

  3. 2023-09-13

    19 health deficiencies · 28 fire-safety deficiencies

    Top issue: Resident Assessment and Care Planning (7 deficiencies)

4

Nursing time per resident, per day

Each resident here gets about 3 h 28 min of nursing staff time a day, 59 min of it from a registered nurse.

This home

3 h 28 min

Washington average

4 h 25 min

U.S. average

3 h 54 min

  • Registered nurse
  • Licensed practical nurse
  • Nurse aide

Turnover: 46% of nursing staff and 42% of registered nurses left in the past year.

Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.

5

Resident outcomes

Quality measures compared with state and national averages. Most come from assessments the home itself reports.

MeasureThis homeStateU.S.
Number of hospitalizations per 1000 long-stay resident days1.6 pts worse2.91.31.8
Number of outpatient emergency department visits per 1000 long-stay resident days0.7 pts better0.81.51.7
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.6 pts worse93.6%96.2%93.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.6 pts better96.9%94.3%95.3%
Percentage of long-stay residents experiencing one or more falls with major injury1 pts worse3.6%2.6%3.2%
Percentage of long-stay residents who have depressive symptoms13.1 pts better4.8%17.9%13.5%
Percentage of long-stay residents who lose too much weight2.9 pts better2.7%5.6%5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medicationAbout the same12.5%12.5%19.5%
Percentage of long-stay residents who received an antipsychotic medication7.7 pts better7.3%15.0%15.4%
Percentage of long-stay residents who were physically restrained0.1 pts better0.0%0.1%0.1%
Percentage of long-stay residents whose ability to walk independently worsened8.9 pts better6.7%15.6%12.7%
Percentage of long-stay residents whose need for help with daily activities has increased5.4 pts better8.4%13.8%13.5%
Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better0.5%0.8%0.7%
Percentage of long-stay residents with a urinary tract infection1.1 pts better0.6%1.7%1.5%
Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.4 pts better16.2%21.6%18.3%
Percentage of long-stay residents with pressure ulcers0.1 pts worse4.5%4.4%4.5%
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine18.3 pts worse70.4%88.7%82.3%
Percentage of short-stay residents who had an outpatient emergency department visit6.6 pts better6.4%13.0%11.8%
Percentage of short-stay residents who newly received an antipsychotic medication0.7 pts better0.6%1.3%1.5%
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine19.6 pts worse64.8%84.4%80.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission7.5 pts worse27.2%19.7%23.4%

·

Who owns and runs it

20 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.

Show ownership list
NameRoleShareHomes
820 Nw 95th Street Property LLCAdp Of The SNF · Organization0%1 facilities
9560 Pico LLCAdp Of The SNF · Organization0%7 facilities
Berg, MichaelCorporate Officer · Individual0%165 facilities
Bhumkar, NishitaOperational/Managerial Control · Individual0%5 facilities
Bhumkar, NishitaAdp Of The SNF · Individual0%5 facilities
Bold Quail Holdings LLCAdp Of The SNF · Organization0%4 facilities
Bq Realty Holdings LLCAdp Of The SNF · Organization0%5 facilities
Brito, JoseOperational/Managerial Control · Individual0%1 facilities
Brito, JoseAdp Of The SNF · Individual0%1 facilities
Newgen Administrative Services, LLCAdp Of The SNF · Organization0%30 facilities
Newgen LLCAdp Of The SNF · Organization0%8 facilities
Pico Ar LLCAdp Of The SNF · Organization0%7 facilities
Robin, AaronCorporate Officer · Individual0%29 facilities
Robin, AaronOperational/Managerial Control · Individual0%29 facilities
Robin, AaronAdp Of The SNF · Individual0%29 facilities
Shaw, PamelaOperational/Managerial Control · Individual0%39 facilities
Tress, AvrohomCorporate Officer · Individual0%30 facilities
Tress, AvrohomOperational/Managerial Control · Individual0%30 facilities
Tress, AvrohomAdp Of The SNF · Individual0%30 facilities
Zhou, TianziangOperational/Managerial Control · Individual0%1 facilities

·

Fire safety

97 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.

Emergency Preparedness32F
  1. F

    Address subsistence needs for staff and patients.

    April 16, 2026 · E15 · Corrected May 9, 2026

  2. F

    Establish procedures for tracking staff and patients during an emergency.

    April 16, 2026 · E18 · Corrected May 9, 2026

  3. F

    Establish policies and procedures including evacuation.

    April 16, 2026 · E20 · Corrected May 24, 2026

  4. F

    Establish policies and procedures for medical documentation.

    April 16, 2026 · E23 · Corrected May 9, 2026

  5. F

    Provide a means of sharing information on occupancy/needs.

    April 16, 2026 · E34 · Corrected May 9, 2026

  6. F

    Provide family notifications of emergency plan.

    April 16, 2026 · E35 · Corrected May 9, 2026

  7. F

    Establish emergency prep training and testing.

    April 16, 2026 · E36 · Corrected May 24, 2026

  8. F

    Establish staff and initial training requirements.

    April 16, 2026 · E37 · Corrected June 26, 2026

  9. F

    Conduct testing and exercise requirements.

    April 16, 2026 · E39 · Corrected May 24, 2026

  10. F

    Develop and maintain an Emergency Preparedness Program (EP).

    April 16, 2026 · E4 · Corrected June 26, 2026

  11. F

    Address patient/client population and determine types of services needed.

    April 16, 2026 · E7 · Corrected May 9, 2026

  12. F

    Include a process for Emergency Preparedness collaboration.

    April 16, 2026 · E9 · Corrected May 9, 2026

  13. D

    List the names and contact information of those in the facility.

    April 16, 2026 · E30 · Corrected May 9, 2026

  14. F

    Address subsistence needs for staff and patients.

    January 8, 2025 · E15 · Corrected March 6, 2025

  15. F

    Establish policies and procedures including evacuation.

    January 8, 2025 · E20 · Corrected March 27, 2025

  16. F

    Establish policies and procedures for sheltering.

    January 8, 2025 · E22 · Corrected February 10, 2025

  17. F

    Establish policies and procedures for volunteers.

    January 8, 2025 · E24 · Corrected February 10, 2025

  18. F

    Establish roles under a Waiver declared by secretary.

    January 8, 2025 · E26 · Corrected February 10, 2025

  19. F

    List the names and contact information of those in the facility.

    January 8, 2025 · E30 · Corrected February 10, 2025

  20. F

    Establish methods for sharing information.

    January 8, 2025 · E33 · Corrected February 10, 2025

  21. F

    Establish emergency prep training and testing.

    January 8, 2025 · E36 · Corrected March 27, 2025

  22. F

    Establish staff and initial training requirements.

    January 8, 2025 · E37 · Corrected March 27, 2025

  23. F

    Conduct testing and exercise requirements.

    January 8, 2025 · E39 · Corrected February 10, 2025

  24. F

    Develop and maintain an Emergency Preparedness Program (EP).

    January 8, 2025 · E4 · Corrected February 10, 2025

  25. F

    Include a process for Emergency Preparedness collaboration.

    January 8, 2025 · E9 · Corrected February 10, 2025

  26. F

    Develop Emergency Preparedness policies and procedures.

    September 13, 2023 · E13 · Corrected October 19, 2023

  27. F

    Develop a communication plan.

    September 13, 2023 · E29 · Corrected October 19, 2023

  28. F

    Establish emergency prep training and testing.

    September 13, 2023 · E36 · Corrected October 19, 2023

  29. F

    Establish staff and initial training requirements.

    September 13, 2023 · E37 · Corrected October 19, 2023

  30. F

    Conduct testing and exercise requirements.

    September 13, 2023 · E39 · Corrected December 14, 2023

  31. F

    Develop and maintain an Emergency Preparedness Program (EP).

    September 13, 2023 · E4 · Corrected October 19, 2023

  32. F

    Include a process for Emergency Preparedness collaboration.

    September 13, 2023 · E9 · Corrected October 19, 2023

Smoke19F
  1. F

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    April 16, 2026 · K321 · Corrected May 9, 2026

  2. F

    Provide properly protected cooking facilities.

    April 16, 2026 · K324 · Corrected May 24, 2026

  3. F

    Have approved installation, maintenance and testing program for fire alarm systems.

    April 16, 2026 · K345 · Corrected May 24, 2026

  4. F

    Follow proper procedures when the fire alarm was out of service for more than 4 hours.

    April 16, 2026 · K346 · Corrected May 24, 2026

  5. F

    Inspect, test, and maintain automatic sprinkler systems.

    April 16, 2026 · K353 · Corrected May 24, 2026

  6. F

    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

    April 16, 2026 · K354 · Corrected May 24, 2026

  7. F

    Install corridor and hallway doors that block smoke.

    April 16, 2026 · K363 · Corrected May 9, 2026

  8. F

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    April 16, 2026 · K374 · Corrected May 24, 2026

  9. D

    Have properly installed hallway dispensers for alcohol-based hand rub.

    April 16, 2026 · K325 · Corrected May 9, 2026

  10. D

    Properly select, install, inspect, or maintain portable fire extinguishes.

    April 16, 2026 · K355 · Corrected May 9, 2026

  11. F

    Provide properly protected cooking facilities.

    January 8, 2025 · K324 · Corrected February 10, 2025

  12. F

    Have approved installation, maintenance and testing program for fire alarm systems.

    January 8, 2025 · K345 · Corrected March 6, 2025

  13. F

    Inspect, test, and maintain automatic sprinkler systems.

    January 8, 2025 · K353 · Corrected March 6, 2025

  14. F

    Provide properly protected cooking facilities.

    September 13, 2023 · K324 · Corrected December 14, 2023

  15. F

    Have approved installation, maintenance and testing program for fire alarm systems.

    September 13, 2023 · K345 · Corrected December 14, 2023

  16. F

    Follow proper procedures when the fire alarm was out of service for more than 4 hours.

    September 13, 2023 · K346 · Corrected October 19, 2023

  17. F

    Inspect, test, and maintain automatic sprinkler systems.

    September 13, 2023 · K353 · Corrected December 14, 2023

  18. F

    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

    September 13, 2023 · K354 · Corrected October 19, 2023

  19. F

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    September 13, 2023 · K374 · Corrected October 19, 2023

Gas, Vacuum, and Electrical Systems14F
  1. F

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

    April 16, 2026 · K914 · Corrected May 24, 2026

  2. F

    Have generator or other power source capable of supplying service within 10 seconds.

    April 16, 2026 · K918 · Corrected May 24, 2026

  3. F

    Ensure proper usage of power strips and extension cords.

    April 16, 2026 · K920 · Corrected May 9, 2026

  4. F

    Ensure that testing and maintenance of electrical equipment is performed.

    April 16, 2026 · K921 · Corrected May 24, 2026

  5. F

    Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

    April 16, 2026 · K926 · Corrected May 24, 2026

  6. F

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

    January 8, 2025 · K914 · Corrected March 6, 2025

  7. F

    Have generator or other power source capable of supplying service within 10 seconds.

    January 8, 2025 · K918 · Corrected March 6, 2025

  8. F

    Ensure that testing and maintenance of electrical equipment is performed.

    January 8, 2025 · K921 · Corrected March 27, 2025

  9. F

    Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

    January 8, 2025 · K926 · Corrected February 10, 2025

  10. D

    Ensure proper usage of power strips and extension cords.

    January 8, 2025 · K920 · Corrected February 10, 2025

  11. F

    Have generator or other power source capable of supplying service within 10 seconds.

    September 13, 2023 · K918 · Corrected October 19, 2023

  12. F

    Ensure that testing and maintenance of electrical equipment is performed.

    September 13, 2023 · K921 · Corrected December 14, 2023

  13. F

    Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

    September 13, 2023 · K926 · Corrected October 19, 2023

  14. F

    Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

    September 13, 2023 · K927 · Corrected December 14, 2023

Miscellaneous13F
  1. F

    Provide a written emergency evacuation plan.

    April 16, 2026 · K711 · Corrected May 24, 2026

  2. F

    Have simulated fire drills held at unexpected times.

    April 16, 2026 · K712 · Corrected May 9, 2026

  3. F

    Have restrictions on the use of highly flammable decorations.

    April 16, 2026 · K753 · Corrected May 9, 2026

  4. F

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    April 16, 2026 · K761 · Corrected May 24, 2026

  5. F

    Have restrictions on the use of portable space heaters.

    April 16, 2026 · K781 · Corrected May 9, 2026

  6. F

    Have simulated fire drills held at unexpected times.

    January 8, 2025 · K712 · Corrected February 10, 2025

  7. F

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

    January 8, 2025 · K741 · Corrected February 10, 2025

  8. F

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    January 8, 2025 · K761 · Corrected February 10, 2025

  9. D

    Have restrictions on the use of portable space heaters.

    January 8, 2025 · K781 · Corrected February 10, 2025

  10. F

    Provide a written emergency evacuation plan.

    September 13, 2023 · K711 · Corrected October 19, 2023

  11. F

    Have simulated fire drills held at unexpected times.

    September 13, 2023 · K712 · Corrected October 19, 2023

  12. F

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

    September 13, 2023 · K741 · Corrected October 19, 2023

  13. F

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    September 13, 2023 · K761 · Corrected October 19, 2023

Egress11F
  1. F

    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.

    April 16, 2026 · K222 · Corrected May 24, 2026

  2. F

    Install emergency lighting that can last at least 1 1/2 hours.

    April 16, 2026 · K291 · Corrected May 24, 2026

  3. F

    Have properly located and lighted "Exit" signs.

    April 16, 2026 · K293 · Corrected May 24, 2026

  4. F

    Install emergency lighting that can last at least 1 1/2 hours.

    January 8, 2025 · K291 · Corrected February 10, 2025

  5. F

    Have properly located and lighted "Exit" signs.

    January 8, 2025 · K293 · Corrected February 10, 2025

  6. E

    Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

    January 8, 2025 · K227 · Corrected February 10, 2025

  7. E

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

    January 8, 2025 · K232 · Corrected February 10, 2025

  8. F

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    September 13, 2023 · K211 · Corrected October 19, 2023

  9. F

    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.

    September 13, 2023 · K222 · Corrected October 19, 2023

  10. F

    Install emergency lighting that can last at least 1 1/2 hours.

    September 13, 2023 · K291 · Corrected October 19, 2023

  11. F

    Have properly located and lighted "Exit" signs.

    September 13, 2023 · K293 · Corrected October 19, 2023

Services6F
  1. F

    Have properly installed electrical wiring and gas equipment.

    April 16, 2026 · K511 · Corrected May 9, 2026

  2. F

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    April 16, 2026 · K521 · Corrected June 24, 2026

  3. F

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    January 8, 2025 · K521 · Corrected February 10, 2025

  4. F

    Have elevators that firefighters can control in the event of a fire.

    September 13, 2023 · K531 · Corrected October 19, 2023

  5. D

    Have properly installed electrical wiring and gas equipment.

    September 13, 2023 · K511 · Corrected October 19, 2023

  6. D

    Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly.

    September 13, 2023 · K523 · Corrected October 19, 2023

Construction2F
  1. F

    Meet other general requirements.

    April 16, 2026 · K100 · Corrected May 24, 2026

  2. E

    Use approved construction type or materials.

    April 16, 2026 · K161 · Corrected May 9, 2026

·

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