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

Blue Springs Wellness & Rehabilitation

930 Ne Duncan Road, Blue Springs, MO · (816) 229-6677

  • Cited for abuse (CMS abuse icon)

CMS overall rating

1 of 5

Compare with a nearby home →
Certified beds
120
Residents per day
106
Ownership
For-Profit
Chain
Opco Skilled Management
Medicare / Medicaid
Medicare + Medicaid
Certified since
December 1, 1994

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 Missouri.

  2. Staffing

    −1 star

    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.

This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.

2

Where it sits among Missouri homes

Blue Springs Wellness & Rehabilitation carries 126.75 inspection points. That is fewer than 29% of Missouri's 479 rated homes.

5★4★3★2★1★+15 homes above 391.2505102550100200inspection points → fewer is better on the leftThis home · 126.75 pts · 2★

Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Missouri: 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★ 0–20 pts
  • 4★ 20–54 pts
  • 3★ 54–93.75 pts
  • 2★ 93.75–159 pts
  • 1★ over 159 pts

Bars show every rated home in Missouri 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

66 health citations on record since 2022. 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 1 50 pts
K 0 100 pts
L 0 150 pts

Actual harmA resident was hurt

G 1 20 pts
H 0 35 pts
I 0 45 pts

Potential for harmNo one was hurt, but could have been

D 34 4 pts
E 26 8 pts
F 4 16 pts

Minimal harmPaperwork-level problems

A 0 0 pts
B 0 0 pts
C 0 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.

Harm and immediate-jeopardy citations (2)

  1. G

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    November 18, 2025 · Complaint inspection · Freedom from Abuse, Neglect, and Exploitation · F600 · Not yet marked corrected

  2. J

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

    October 3, 2024 · Complaint inspection · Quality of Life and Care · F689 · Corrected October 1, 2024

Everything else, by area of care

Resident Rights14E
  1. D

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    July 16, 2026 · Complaint · F550 · Corrected July 10, 2026

  2. D

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

    March 28, 2025 · Standard · F578 · Corrected May 12, 2025

  3. E

    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.

    December 2, 2024 · Complaint · F584 · Corrected January 15, 2025

  4. D

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    April 22, 2024 · Complaint · F561 · Corrected June 7, 2024

  5. E

    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.

    July 21, 2023 · Standard · F584 · Corrected September 1, 2023

  6. D

    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

    July 21, 2023 · Standard · F557 · Corrected September 1, 2023

  7. D

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

    July 21, 2023 · Standard · F623 · Corrected September 1, 2023

  8. 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.

    July 21, 2023 · Standard · F625 · Corrected September 1, 2023

  9. E

    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

    April 7, 2022 · Standard · F569 · Corrected May 11, 2022

  10. E

    Assure the security of all personal funds of residents deposited with the facility.

    April 7, 2022 · Standard · F570 · Corrected May 11, 2022

  11. E

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    April 7, 2022 · Standard · F582 · Corrected May 11, 2022

  12. E

    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.

    April 7, 2022 · Standard · F584 · Corrected May 11, 2022

  13. D

    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

    April 7, 2022 · Standard · F568 · Corrected May 11, 2022

  14. D

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

    April 7, 2022 · Standard · F578 · Corrected May 11, 2022

Quality of Life and Care13E
  1. D

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    March 28, 2025 · Standard · F693 · Corrected May 12, 2025

  2. D

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

    March 28, 2025 · Standard · F695 · Corrected May 12, 2025

  3. D

    Provide care or services that was trauma informed and/or culturally competent.

    March 28, 2025 · Standard · F699 · Corrected May 12, 2025

  4. D

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    March 28, 2025 · Standard · F744 · Corrected May 12, 2025

  5. E

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

    July 21, 2023 · Standard · F695 · Corrected September 1, 2023

  6. D

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

    July 21, 2023 · Standard · F677 · Corrected September 1, 2023

  7. D

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    July 21, 2023 · Standard · F686 · Corrected September 1, 2023

  8. D

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

    July 21, 2023 · Standard · F689 · Corrected September 1, 2023

  9. D

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    July 21, 2023 · Standard · F690 · Corrected September 1, 2023

  10. D

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

    April 7, 2022 · Standard · F685 · Corrected May 11, 2022

  11. D

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

    April 7, 2022 · Standard · F689 · Corrected May 11, 2022

  12. D

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    April 7, 2022 · Standard · F693 · Corrected May 11, 2022

  13. D

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

    April 7, 2022 · Standard · F740 · Corrected May 11, 2022

Resident Assessment and Care Planning9E
  1. D

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

    March 28, 2025 · Standard · F658 · Corrected May 12, 2025

  2. E

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

    July 21, 2023 · Standard · F656 · Corrected September 1, 2023

  3. D

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

    July 21, 2023 · Standard · F636 · Corrected September 1, 2023

  4. E

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

    April 7, 2022 · Standard · F638 · Corrected May 11, 2022

  5. E

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

    April 7, 2022 · Standard · F640 · Corrected May 11, 2022

  6. E

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

    April 7, 2022 · Standard · F656 · Corrected May 11, 2022

  7. D

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

    April 7, 2022 · Standard · F636 · Corrected May 11, 2022

  8. D

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

    April 7, 2022 · Standard · F655 · Corrected May 11, 2022

  9. 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 7, 2022 · Standard · F657 · Corrected May 11, 2022

Nutrition and Dietary8E
  1. D

    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

    March 28, 2025 · Standard · F805 · Corrected May 12, 2025

  2. E

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

    July 21, 2023 · Standard · F804 · Corrected September 1, 2023

  3. E

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

    July 21, 2023 · Standard · F812 · Corrected September 1, 2023

  4. D

    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

    July 21, 2023 · Standard · F800 · Corrected September 1, 2023

  5. E

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

    April 7, 2022 · Standard · F804 · Corrected May 11, 2022

  6. E

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

    April 7, 2022 · Standard · F812 · Corrected May 11, 2022

  7. E

    Have a policy regarding use and storage of foods brought to residents by family and other visitors.

    April 7, 2022 · Standard · F813 · Corrected May 11, 2022

  8. E

    Dispose of garbage and refuse properly.

    April 7, 2022 · Standard · F814 · Corrected May 11, 2022

Pharmacy Service7E
  1. D

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

    November 18, 2025 · Complaint · F755 · Not yet marked corrected

  2. E

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    March 28, 2025 · Standard · F756 · Corrected May 12, 2025

  3. D

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

    March 28, 2025 · Standard · F755 · Corrected May 12, 2025

  4. D

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

    March 28, 2025 · Standard · F758 · Corrected May 12, 2025

  5. D

    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.

    March 28, 2025 · Standard · F761 · Corrected May 12, 2025

  6. E

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    July 21, 2023 · Standard · F756 · Corrected September 1, 2023

  7. 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.

    July 21, 2023 · Standard · F761 · Corrected September 1, 2023

Infection Control5F
  1. D

    Provide and implement an infection prevention and control program.

    March 28, 2025 · Standard · F880 · Corrected May 12, 2025

  2. F

    Provide and implement an infection prevention and control program.

    July 21, 2023 · Standard · F880 · Corrected September 1, 2023

  3. F

    Implement a program that monitors antibiotic use.

    July 21, 2023 · Standard · F881 · Corrected September 1, 2023

  4. D

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

    July 21, 2023 · Standard · F883 · Corrected September 1, 2023

  5. F

    Provide and implement an infection prevention and control program.

    April 7, 2022 · Standard · F880 · Corrected May 11, 2022

Environmental5F
  1. F

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

    July 21, 2023 · Standard · F925 · Corrected September 1, 2023

  2. E

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    July 21, 2023 · Standard · F921 · Corrected September 1, 2023

  3. E

    Have enough outside ventilation via a window or mechanical ventilation, or both.

    July 21, 2023 · Standard · F923 · Corrected September 1, 2023

  4. E

    Make sure that a working call system is available in each resident's bathroom and bathing area.

    April 7, 2022 · Standard · F919 · Corrected May 11, 2022

  5. E

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    April 7, 2022 · Standard · F921 · Corrected May 11, 2022

Nursing and Physician Services2E
  1. E

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

    July 21, 2023 · Standard · F947 · Corrected September 1, 2023

  2. E

    Post nurse staffing information every day.

    April 7, 2022 · Standard · F732 · Corrected May 11, 2022

Freedom from Abuse, Neglect, and Exploitation1D
  1. D

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    July 16, 2026 · Complaint · F600 · Corrected July 14, 2026

Inspection history

  1. 2025-03-28

    16 health deficiencies · 5 fire-safety deficiencies

    Top issue: Pharmacy Service (5 deficiencies)

  2. 2023-07-21

    25 health deficiencies · 13 fire-safety deficiencies

    Top issue: Quality of Life and Care (6 deficiencies)

  3. 2022-04-07

    25 health deficiencies · 20 fire-safety deficiencies

    Top issue: Resident Rights (7 deficiencies)

4

Nursing time per resident, per day

Each resident here gets about 2 h 53 min of nursing staff time a day, 15 min of it from a registered nurse.

This home

2 h 53 min

Missouri average

3 h 24 min

U.S. average

3 h 54 min

  • Registered nurse
  • Licensed practical nurse
  • Nurse aide

Turnover: 65% of nursing staff and 50% 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

Fines and payment denials

$96,959 in federal fines on record over the past three years.

DatePenaltyAmount
2024-09-27Fine$96,959

6

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 days0.3 pts better1.72.01.8
Number of outpatient emergency department visits per 1000 long-stay resident days1.1 pts better1.12.21.7
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine10.5 pts better94.5%84.0%93.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine5.4 pts better96.2%90.8%95.3%
Percentage of long-stay residents experiencing one or more falls with major injury2.6 pts better1.4%4.0%3.2%
Percentage of long-stay residents who have depressive symptoms31.5 pts worse51.5%20.0%13.5%
Percentage of long-stay residents who lose too much weight4.6 pts worse9.7%5.1%5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication2.8 pts better22.8%25.6%19.5%
Percentage of long-stay residents who received an antipsychotic medication7.2 pts better16.3%23.5%15.4%
Percentage of long-stay residents who were physically restrainedAbout the same0.0%0.0%0.1%
Percentage of long-stay residents whose ability to walk independently worsened11.3 pts better4.5%15.8%12.7%
Percentage of long-stay residents whose need for help with daily activities has increased11.7 pts better5.7%17.4%13.5%
Percentage of long-stay residents with a catheter inserted and left in their bladder0.9 pts better0.0%0.9%0.7%
Percentage of long-stay residents with a urinary tract infection1.3 pts better0.9%2.2%1.5%
Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.2 pts better16.9%17.1%18.3%
Percentage of long-stay residents with pressure ulcers0.4 pts worse4.8%4.4%4.5%
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine29.4 pts better95.1%65.7%82.3%
Percentage of short-stay residents who had an outpatient emergency department visit7.5 pts better5.9%13.4%11.8%
Percentage of short-stay residents who newly received an antipsychotic medication2.1 pts better0.0%2.1%1.5%
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine21.9 pts better83.3%61.4%80.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission15.5 pts worse41.2%25.7%23.4%

·

Who owns and runs it

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

Show ownership list
NameRoleShareHomes
Wildflower Healthcare LLC5% Or Greater Direct Ownership Interest · Organization100%5 facilities
930 Ne Duncan Road Mo, LLC5% Or Greater Mortgage Interest · Organization0%1 facilities
930 Ne Duncan Road Mo, LLCAdp Of The SNF · Organization0%1 facilities
Blooming Willow Partners LLC5% Or Greater Indirect Ownership Interest · Organization0%5 facilities
Braswell, AmandaAdp Of The SNF · Individual0%1 facilities
Brook Partners LLC5% Or Greater Mortgage Interest · Organization0%4 facilities
Brook Partners LLCAdp Of The SNF · Organization0%4 facilities
Chung, RichardAdp Of The SNF · Individual0%1 facilities
Davidovich, NivTrustee Of The SNF · Individual0%26 facilities
Derhoben Trust5% Or Greater Indirect Ownership Interest · Organization0%5 facilities
Garetz, DavidIndirect Ownership Interest · Individual0%72 facilities
Garetz, DavidCorporate Officer · Individual0%72 facilities
Garetz, DavidOperational/Managerial Control · Individual0%72 facilities
Hagins, ElizabethIndividual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual0%57 facilities
Kaplan, MordechaiIndividual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual0%42 facilities
Knobel Realty Trust5% Or Greater Mortgage Interest · Organization0%4 facilities
Knobel Realty TrustAdp Of The SNF · Organization0%4 facilities
Linz Trust5% Or Greater Mortgage Interest · Organization0%11 facilities
Linz TrustAdp Of The SNF · Organization0%11 facilities
Mindle, AdamIndividual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual0%58 facilities
Pas B Sol Trust5% Or Greater Indirect Ownership Interest · Organization0%5 facilities
Rembrandt Realty Trust5% Or Greater Mortgage Interest · Organization0%4 facilities
Rembrandt Realty TrustAdp Of The SNF · Organization0%4 facilities
Sesame Realty Trust5% Or Greater Mortgage Interest · Organization0%4 facilities
Sesame Realty TrustAdp Of The SNF · Organization0%4 facilities
Sternshein, JenniferTrustee Of The SNF · Individual0%55 facilities
Wildflower Healthcare LLCOperational/Managerial Control · Organization0%5 facilities
Willowbrook Investors LLC5% Or Greater Mortgage Interest · Organization0%3 facilities
Willowbrook Investors LLCAdp Of The SNF · Organization0%3 facilities
Zimmerman, CarolineIndividual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual0%35 facilities

·

Fire safety

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

Smoke16F
  1. F

    Inspect, test, and maintain automatic sprinkler systems.

    December 2, 2024 · K353 · Corrected January 15, 2025

  2. F

    Provide properly protected cooking facilities.

    October 17, 2024 · K324 · Corrected October 23, 2024

  3. F

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

    July 21, 2023 · K345 · Corrected September 1, 2023

  4. E

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

    July 21, 2023 · K321 · Corrected September 1, 2023

  5. E

    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

    July 21, 2023 · K362 · Corrected September 1, 2023

  6. E

    Install corridor and hallway doors that block smoke.

    July 21, 2023 · K363 · Corrected September 1, 2023

  7. E

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    July 21, 2023 · K372 · Corrected September 1, 2023

  8. E

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

    July 21, 2023 · K374 · Corrected September 1, 2023

  9. F

    Inspect, test, and maintain automatic sprinkler systems.

    April 7, 2022 · K353 · Corrected May 11, 2022

  10. F

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

    April 7, 2022 · K354 · Corrected May 11, 2022

  11. E

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

    April 7, 2022 · K321 · Corrected May 11, 2022

  12. E

    Provide properly protected cooking facilities.

    April 7, 2022 · K324 · Corrected May 11, 2022

  13. E

    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

    April 7, 2022 · K362 · Corrected May 11, 2022

  14. E

    Install corridor and hallway doors that block smoke.

    April 7, 2022 · K363 · Corrected May 11, 2022

  15. E

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    April 7, 2022 · K372 · Corrected May 11, 2022

  16. E

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

    April 7, 2022 · K374 · Corrected May 11, 2022

Emergency Preparedness9F
  1. F

    Conduct testing and exercise requirements.

    March 28, 2025 · E39 · Corrected May 12, 2025

  2. F

    Establish policies and procedures including evacuation.

    July 21, 2023 · E20 · Corrected September 1, 2023

  3. F

    Create arrangements with other facilities to receive patients.

    July 21, 2023 · E25 · Corrected September 1, 2023

  4. F

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

    July 21, 2023 · E30 · Corrected September 1, 2023

  5. E

    Address subsistence needs for staff and patients.

    July 21, 2023 · E15 · Corrected September 1, 2023

  6. F

    Address subsistence needs for staff and patients.

    April 7, 2022 · E15 · Corrected May 11, 2022

  7. F

    Establish policies and procedures including evacuation.

    April 7, 2022 · E20 · Corrected May 11, 2022

  8. F

    Create arrangements with other facilities to receive patients.

    April 7, 2022 · E25 · Corrected May 11, 2022

  9. F

    Implement emergency and standby power systems.

    April 7, 2022 · E41 · Corrected May 11, 2022

Gas, Vacuum, and Electrical Systems5F
  1. F

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

    March 28, 2025 · K914 · Corrected May 12, 2025

  2. F

    Ensure proper usage of power strips and extension cords.

    March 28, 2025 · K920 · Corrected May 12, 2025

  3. E

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

    March 28, 2025 · K918 · Corrected May 12, 2025

  4. E

    Meet requirements for the use of electrical equipment.

    April 7, 2022 · K919 · Corrected May 11, 2022

  5. D

    Have proper medical gas storage and administration areas.

    April 7, 2022 · K923 · Corrected May 11, 2022

Miscellaneous4F
  1. E

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

    March 28, 2025 · K741 · Corrected May 12, 2025

  2. F

    Have simulated fire drills held at unexpected times.

    July 21, 2023 · K712 · Corrected September 1, 2023

  3. F

    Have simulated fire drills held at unexpected times.

    April 7, 2022 · K712 · Corrected May 11, 2022

  4. E

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

    April 7, 2022 · K761 · Corrected May 11, 2022

Egress3F
  1. F

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

    April 7, 2022 · K291 · Corrected May 11, 2022

  2. E

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

    April 7, 2022 · K211 · Corrected May 11, 2022

  3. E

    Meet other general requirements that are deficient.

    April 7, 2022 · K300 · Corrected May 11, 2022

Services1E
  1. E

    Meet other general requirements that are deficient.

    April 7, 2022 · K500 · Corrected May 11, 2022

·

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