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

Medina Center For Rehabilitation And Nursing

555 Springbrook Dr, Medina, OH · (330) 725-3393

  • Special Focus Facility

CMS overall rating

2 of 5

Compare with a nearby home →
Certified beds
80
Residents per day
69
Ownership
For-Profit
Chain
Aom Healthcare
Medicare / Medicaid
Medicare + Medicaid
Certified since
October 28, 1985

1

How this home got 2 stars

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 Ohio.

  2. Staffing

    no change (already 1)

    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

    +1 star

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

  4. Overall

    2 of 5

    Matches the rating CMS publishes on Care Compare.

2

Where it sits among Ohio homes

Medina Center For Rehabilitation And Nursing carries 360.25 inspection points. That is fewer than 1% of Ohio's 913 rated homes.

5★4★3★2★1★+7 homes above 378.2605102550100200inspection points → fewer is better on the leftThis home · 360.25 pts · 1★

Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Ohio: 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★ 0–15 pts
  • 4★ 15–42 pts
  • 3★ 42–69 pts
  • 2★ 69–121.25 pts
  • 1★ over 121.25 pts

Bars show every rated home in Ohio 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

100 health citations on record since 2020. 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 3 20 pts
H 0 35 pts
I 0 45 pts

Potential for harmNo one was hurt, but could have been

D 56 4 pts
E 17 8 pts
F 20 16 pts

Minimal harmPaperwork-level problems

A 0 0 pts
B 0 0 pts
C 3 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 (4)

  1. J

    Ensure that residents are free from significant medication errors.

    April 22, 2025 · Complaint inspection · Pharmacy Service · F760 · Corrected May 2, 2025

  2. G

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

    February 25, 2025 · Complaint inspection · Quality of Life and Care · F689 · Corrected April 22, 2025

  3. G

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

    October 9, 2024 · Complaint inspection · Quality of Life and Care · F690 · Corrected November 6, 2024

  4. G

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

    December 12, 2023 · Complaint inspection · Quality of Life and Care · F690 · Corrected January 12, 2024

Everything else, by area of care

Quality of Life and Care18E
  1. E

    Provide activities to meet all resident's needs.

    August 14, 2025 · Complaint · F679 · Corrected August 15, 2025

  2. D

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

    April 22, 2025 · Complaint · F677 · Corrected May 2, 2025

  3. D

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

    April 22, 2025 · Complaint · F684 · Corrected May 2, 2025

  4. D

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

    February 25, 2025 · Standard · F677 · Corrected May 2, 2025

  5. D

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

    February 25, 2025 · Complaint · F684 · Corrected May 2, 2025

  6. D

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

    November 27, 2024 · Complaint · F695 · Corrected November 29, 2024

  7. E

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

    October 9, 2024 · Complaint · F689 · Corrected November 6, 2024

  8. D

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

    October 9, 2024 · Complaint · F677 · Corrected November 6, 2024

  9. D

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

    October 9, 2024 · Complaint · F684 · Corrected November 6, 2024

  10. 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.

    March 6, 2024 · Complaint · F690 · Corrected March 29, 2024

  11. D

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

    February 12, 2024 · Complaint · F689 · Corrected March 29, 2024

  12. D

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

    December 28, 2023 · Complaint · F689 · Corrected January 12, 2024

  13. D

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

    December 12, 2023 · Complaint · F686 · Corrected January 12, 2024

  14. D

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

    April 24, 2023 · Standard · F684 · Corrected May 31, 2023

  15. D

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

    April 24, 2023 · Standard · F686 · Corrected May 31, 2023

  16. 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.

    April 24, 2023 · Standard · F690 · Corrected May 31, 2023

  17. D

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

    April 24, 2023 · Standard · F695 · Corrected May 31, 2023

  18. 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.

    February 12, 2020 · Standard · F690 · Corrected March 16, 2020

Nutrition and Dietary17F
  1. F

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

    April 22, 2025 · Complaint · F804 · Corrected May 2, 2025

  2. E

    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

    April 22, 2025 · Complaint · F807 · Corrected May 2, 2025

  3. F

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

    February 25, 2025 · Complaint · F804 · Corrected May 2, 2025

  4. F

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

    February 25, 2025 · Standard · F812 · Corrected April 22, 2025

  5. F

    Dispose of garbage and refuse properly.

    February 25, 2025 · Standard · F814 · Corrected April 22, 2025

  6. D

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

    November 27, 2024 · Complaint · F805 · Corrected November 29, 2024

  7. F

    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

    October 9, 2024 · Complaint · F802 · Corrected November 6, 2024

  8. F

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

    October 9, 2024 · Complaint · F804 · Corrected November 6, 2024

  9. F

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

    October 9, 2024 · Complaint · F812 · Corrected November 6, 2024

  10. 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.

    October 9, 2024 · Complaint · F803 · Corrected November 6, 2024

  11. E

    Provide special eating equipment and utensils for residents who need them and appropriate assistance.

    October 9, 2024 · Complaint · F810 · Corrected November 6, 2024

  12. D

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

    October 9, 2024 · Complaint · F806 · Corrected November 6, 2024

  13. F

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

    June 10, 2024 · Complaint · F812 · Corrected June 11, 2024

  14. D

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

    February 12, 2024 · Complaint · F800 · Corrected March 29, 2024

  15. F

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

    December 12, 2023 · Complaint · F804 · Corrected January 12, 2024

  16. E

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

    December 12, 2023 · Complaint · F812 · Corrected January 12, 2024

  17. F

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

    April 24, 2023 · Standard · F812 · Corrected May 31, 2023

Resident Rights11F
  1. 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 22, 2025 · Complaint · F584 · Corrected May 2, 2025

  2. D

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

    April 22, 2025 · Complaint · F550 · Corrected May 2, 2025

  3. F

    Honor the resident's right to organize and participate in resident/family groups in the facility.

    February 25, 2025 · Standard · F565 · Corrected April 22, 2025

  4. D

    Keep residents' personal and medical records private and confidential.

    February 25, 2025 · Standard · F583 · Corrected April 22, 2025

  5. D

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    October 9, 2024 · Complaint · F580 · Corrected November 6, 2024

  6. 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.

    October 9, 2024 · Complaint · F584 · Corrected November 6, 2024

  7. 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 26, 2024 · Complaint · F578 · Corrected March 29, 2024

  8. D

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    March 26, 2024 · Complaint · F580 · Corrected March 29, 2024

  9. D

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    February 12, 2024 · Complaint · F580 · Corrected March 29, 2024

  10. D

    Prepare residents for a safe transfer or discharge from the nursing home.

    December 12, 2023 · Complaint · F624 · Corrected January 12, 2024

  11. D

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    April 24, 2023 · Standard · F580 · Corrected May 31, 2023

Pharmacy Service9E
  1. 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.

    February 25, 2025 · Complaint · F761 · Corrected April 22, 2025

  2. D

    Ensure medication error rates are not 5 percent or greater.

    June 10, 2024 · Complaint · F759 · Corrected June 11, 2024

  3. D

    Ensure that residents are free from significant medication errors.

    June 10, 2024 · Complaint · F760 · Corrected June 11, 2024

  4. D

    Ensure that residents are free from significant medication errors.

    March 26, 2024 · Complaint · F760 · Corrected March 29, 2024

  5. 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.

    December 12, 2023 · Complaint · F761 · Corrected January 12, 2024

  6. E

    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.

    April 24, 2023 · Standard · F758 · Corrected May 31, 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.

    February 12, 2020 · Standard · F761 · Corrected March 16, 2020

  8. D

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

    February 12, 2020 · Standard · F756 · Corrected March 16, 2020

  9. 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.

    February 12, 2020 · Standard · F758 · Corrected March 16, 2020

Freedom from Abuse, Neglect, and Exploitation8F
  1. D

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

    April 22, 2025 · Complaint · F600 · Corrected May 2, 2025

  2. F

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

    October 9, 2024 · Complaint · F607 · Corrected November 6, 2024

  3. D

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

    October 9, 2024 · Complaint · F600 · Corrected November 6, 2024

  4. D

    Protect each resident from the wrongful use of the resident's belongings or money.

    October 9, 2024 · Complaint · F602 · Corrected November 6, 2024

  5. D

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

    October 9, 2024 · Complaint · F604 · Corrected November 6, 2024

  6. D

    Respond appropriately to all alleged violations.

    October 9, 2024 · Complaint · F610 · Corrected November 6, 2024

  7. D

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

    December 12, 2023 · Complaint · F609 · Corrected January 12, 2024

  8. D

    Respond appropriately to all alleged violations.

    December 12, 2023 · Complaint · F610 · Corrected January 12, 2024

Infection Control8F
  1. D

    Provide and implement an infection prevention and control program.

    April 22, 2025 · Complaint · F880 · Corrected May 2, 2025

  2. F

    Provide and implement an infection prevention and control program.

    February 25, 2025 · Complaint · F880 · Corrected May 2, 2025

  3. F

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

    February 25, 2025 · Standard · F882 · Corrected April 22, 2025

  4. D

    Provide and implement an infection prevention and control program.

    June 10, 2024 · Complaint · F880 · Corrected June 11, 2024

  5. E

    Provide and implement an infection prevention and control program.

    December 12, 2023 · Complaint · F880 · Corrected January 12, 2024

  6. D

    Provide and implement an infection prevention and control program.

    April 24, 2023 · Standard · F880 · Corrected May 31, 2023

  7. F

    Implement a program that monitors antibiotic use.

    February 12, 2020 · Standard · F881 · Corrected March 16, 2020

  8. D

    Provide and implement an infection prevention and control program.

    February 12, 2020 · Standard · F880 · Corrected March 16, 2020

Nursing and Physician Services7F
  1. F

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

    February 25, 2025 · Complaint · F725 · Corrected April 22, 2025

  2. F

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

    February 25, 2025 · Complaint · F727 · Corrected April 22, 2025

  3. C

    Post nurse staffing information every day.

    October 9, 2024 · Complaint · F732 · Corrected November 6, 2024

  4. F

    Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

    March 6, 2024 · Complaint · F729 · Corrected March 29, 2024

  5. E

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

    March 6, 2024 · Complaint · F726 · Corrected March 29, 2024

  6. D

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

    December 12, 2023 · Complaint · F726 · Corrected January 12, 2024

  7. F

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

    April 24, 2023 · Standard · F730 · Corrected May 31, 2023

Resident Assessment and Care Planning7E
  1. D

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

    February 25, 2025 · Standard · F656 · Corrected April 22, 2025

  2. E

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    October 9, 2024 · Complaint · F842 · Corrected November 6, 2024

  3. D

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

    October 9, 2024 · Complaint · F657 · Corrected November 6, 2024

  4. D

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    March 26, 2024 · Complaint · F842 · Corrected March 29, 2024

  5. D

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

    December 12, 2023 · Complaint · F656 · Corrected January 12, 2024

  6. D

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

    April 24, 2023 · Standard · F656 · Corrected May 31, 2023

  7. 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 24, 2023 · Standard · F657 · Corrected May 31, 2023

Administration6F
  1. D

    Develop, implement, and/or maintain an effective training program for all new and existing staff members.

    February 25, 2025 · Standard · F940 · Corrected April 22, 2025

  2. 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.

    February 25, 2025 · Standard · F838 · Corrected April 22, 2025

  3. E

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

    October 9, 2024 · Complaint · F949 · Corrected November 6, 2024

  4. C

    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

    October 9, 2024 · Complaint · F851 · Corrected November 6, 2024

  5. E

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    March 6, 2024 · Complaint · F835 · Corrected March 29, 2024

  6. F

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    April 24, 2023 · Standard · F835 · Corrected May 31, 2023

Environmental5E
  1. E

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

    April 22, 2025 · Complaint · F921 · Corrected May 2, 2025

  2. E

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

    February 25, 2025 · Standard · F921 · Corrected May 2, 2025

  3. D

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

    February 25, 2025 · Standard · F919 · Corrected April 22, 2025

  4. D

    Keep all essential equipment working safely.

    November 27, 2024 · Complaint · F908 · Corrected November 29, 2024

  5. D

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

    April 24, 2023 · Standard · F921 · Corrected May 31, 2023

Inspection history

  1. 2025-02-25

    18 health deficiencies · 10 fire-safety deficiencies

    Top issue: Nutrition and Dietary (3 deficiencies)

  2. 2023-04-24

    49 health deficiencies · 13 fire-safety deficiencies

    Top issue: Quality of Life and Care (12 deficiencies)

  3. 2020-02-12

    33 health deficiencies · 12 fire-safety deficiencies

    Top issue: Pharmacy Service (7 deficiencies)

4

Nursing time per resident, per day

Each resident here gets about 3 h 11 min of nursing staff time a day, 26 min of it from a registered nurse.

This home

3 h 11 min

Ohio average

3 h 43 min

U.S. average

3 h 54 min

  • Registered nurse
  • Licensed practical nurse
  • Nurse aide

Turnover: 74% of nursing staff and 80% 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

$136,807 in federal fines on record over the past three years.

DatePenaltyAmount
2025-02-25Fine$17,644
2025-02-25Fine$61,384
2025-02-25Payment Denial · 38 day denial$0
2024-10-09Fine$57,779
2023-12-12Payment Denial · 2 day denial$0

6

Resident outcomes

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

MeasureThis homeStateU.S.
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine35.2 pts worse57.5%92.7%93.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine53.4 pts worse40.3%93.7%95.3%
Percentage of long-stay residents experiencing one or more falls with major injury0.9 pts better2.2%3.1%3.2%
Percentage of long-stay residents who have depressive symptoms1.6 pts worse33.2%31.6%13.5%
Percentage of long-stay residents who lose too much weight2.5 pts better3.6%6.1%5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication1.9 pts better23.6%25.5%19.5%
Percentage of long-stay residents who received an antipsychotic medication2 pts worse10.5%8.5%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 worsened2.4 pts better2.9%5.3%12.7%
Percentage of long-stay residents whose need for help with daily activities has increased0.9 pts better4.1%5.0%13.5%
Percentage of long-stay residents with a catheter inserted and left in their bladder0.2 pts better0.0%0.2%0.7%
Percentage of long-stay residents with a urinary tract infection0.4 pts better0.0%0.4%1.5%
Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.1 pts better20.8%20.9%18.3%
Percentage of long-stay residents with pressure ulcers2.6 pts better0.6%3.2%4.5%
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine44.6 pts worse33.8%78.4%82.3%

·

Who owns and runs it

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

Show ownership list
NameRoleShareHomes
Goldstein, Jeffery5% Or Greater Direct Ownership Interest · Individual49%26 facilities
Sherman, Lea5% Or Greater Direct Ownership Interest · Individual49%5 facilities
Goldstein, JefferyW-2 Managing Employee · Individual0%26 facilities
Goldstein, JefferyCorporate Officer · Individual0%26 facilities

·

Fire safety

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

Smoke11F
  1. F

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

    February 25, 2025 · K345 · Corrected May 2, 2025

  2. F

    Install an approved automatic sprinkler system.

    February 25, 2025 · K351 · Corrected April 22, 2025

  3. E

    Install corridor and hallway doors that block smoke.

    February 25, 2025 · K363 · Corrected April 22, 2025

  4. F

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

    April 24, 2023 · K321 · Corrected May 31, 2023

  5. F

    Provide properly protected cooking facilities.

    April 24, 2023 · K324 · Corrected May 31, 2023

  6. F

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

    April 24, 2023 · K345 · Corrected May 31, 2023

  7. F

    Inspect, test, and maintain automatic sprinkler systems.

    April 24, 2023 · K353 · Corrected May 31, 2023

  8. F

    Install corridor and hallway doors that block smoke.

    April 24, 2023 · K363 · Corrected May 31, 2023

  9. F

    Install corridor and hallway doors that block smoke.

    February 12, 2020 · K363 · Corrected March 16, 2020

  10. D

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

    February 12, 2020 · K362 · Corrected March 16, 2020

  11. C

    Inspect, test, and maintain automatic sprinkler systems.

    February 12, 2020 · K353 · Corrected March 16, 2020

Gas, Vacuum, and Electrical Systems9F
  1. F

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

    February 25, 2025 · K918 · Corrected April 22, 2025

  2. E

    Ensure proper usage of power strips and extension cords.

    February 25, 2025 · K920 · Corrected April 22, 2025

  3. F

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

    April 24, 2023 · K914 · Corrected May 31, 2023

  4. F

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

    April 24, 2023 · K918 · Corrected May 31, 2023

  5. F

    Have proper medical gas storage and administration areas.

    April 24, 2023 · K923 · Corrected May 31, 2023

  6. E

    Meet requirements for the installation and maintenance of electrical systems.

    April 24, 2023 · K911 · Corrected May 31, 2023

  7. E

    Ensure proper usage of power strips and extension cords.

    April 24, 2023 · K920 · Corrected May 31, 2023

  8. F

    Have proper medical gas storage and administration areas.

    February 12, 2020 · K923 · Corrected March 16, 2020

  9. D

    Ensure proper usage of power strips and extension cords.

    February 12, 2020 · K920 · Corrected March 16, 2020

Egress6F
  1. F

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

    February 25, 2025 · K291 · Corrected April 22, 2025

  2. F

    Meet other general requirements that are deficient.

    February 25, 2025 · K300 · Corrected April 22, 2025

  3. E

    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.

    February 25, 2025 · K222 · Corrected April 22, 2025

  4. E

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

    April 24, 2023 · K211 · Corrected May 31, 2023

  5. E

    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 24, 2023 · K222 · Corrected May 31, 2023

  6. F

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

    February 12, 2020 · K291 · Corrected March 16, 2020

Emergency Preparedness4C
  1. C

    Address subsistence needs for staff and patients.

    February 12, 2020 · E15 · Corrected March 16, 2020

  2. C

    Establish policies and procedures for volunteers.

    February 12, 2020 · E24 · Corrected March 16, 2020

  3. C

    Develop a communication plan.

    February 12, 2020 · E29 · Corrected March 16, 2020

  4. C

    Provide a means of sharing information on occupancy/needs.

    February 12, 2020 · E34 · Corrected March 16, 2020

Services3F
  1. F

    Have properly installed electrical wiring and gas equipment.

    February 25, 2025 · K511 · Corrected April 22, 2025

  2. E

    Have properly installed electrical wiring and gas equipment.

    February 12, 2020 · K511 · Corrected March 16, 2020

  3. D

    Have an externally vented heating system.

    February 12, 2020 · K522 · Corrected March 16, 2020

Miscellaneous2F
  1. E

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

    February 25, 2025 · K741 · Corrected April 22, 2025

  2. F

    Have simulated fire drills held at unexpected times.

    April 24, 2023 · K712 · Corrected May 31, 2023

·

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