All citations for Bailey-Boushay House

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Bailey-Boushay House

Last standard health inspection on record

May 5, 2025

Showing 1 to 25 of 30 citations

No harm, with potential for more than minimal harm
Develop and maintain an Emergency Preparedness Program (EP).
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 25, 2023).
No harm, with potential for more than minimal harm
Conduct risk assessment and an All-Hazards approach.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0006, Emergency Preparedness Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 25, 2023).
No harm, with potential for more than minimal harm
Address patient/client population and determine types of services needed.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0007, Emergency Preparedness Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 28, 2023).
No harm, with potential for more than minimal harm
Include a process for Emergency Preparedness collaboration.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0009, Emergency Preparedness Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 28, 2023).
No harm, with potential for more than minimal harm
Develop Emergency Preparedness policies and procedures.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0013, Emergency Preparedness Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (May 16, 2023).
No harm, with potential for more than minimal harm
Develop a communication plan.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0029, Emergency Preparedness Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 25, 2023).
No harm, with potential for more than minimal harm
Conduct testing and exercise requirements.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 28, 2023).
No harm, with potential for more than minimal harm
Meet the requirements of an integrated health system.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0042, Emergency Preparedness Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 28, 2023).
No harm, with potential for more than minimal harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Widespread (many residents). CMS level F.
Fire safety citation K-0225, Egress Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 28, 2023).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 28, 2023).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
A waiver was granted (May 16, 2023).
No harm, with potential for more than minimal harm
Have elevators that firefighters can control in the event of a fire.
Widespread (many residents). CMS level F.
Fire safety citation K-0531, Services Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (May 16, 2023).
No harm, with potential for more than minimal harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Widespread (many residents). CMS level F.
Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 28, 2023).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Widespread (many residents). CMS level F.
Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
A waiver was granted (May 16, 2023).
No harm, with potential for more than minimal harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Widespread (many residents). CMS level F.
Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
A waiver was granted (May 16, 2023).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
Widespread (many residents). CMS level F.
Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
A waiver was granted (May 16, 2023).
No harm, with potential for more than minimal harm
Ensure that testing and maintenance of electrical equipment is performed.
Widespread (many residents). CMS level F.
Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
A waiver was granted (May 16, 2023).
No harm, with potential for more than minimal harm
Have proper medical gas storage and administration areas.
Widespread (many residents). CMS level F.
Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 28, 2023).
No harm, with potential for more than minimal harm
Ensure that residents are fully informed and understand their health status, care and treatments.
Pattern (more than a few residents). CMS level E.
Health citation F-0552, Resident Rights Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 14, 2023).
No harm, with potential for more than minimal harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Pattern (more than a few residents). CMS level E.
Health citation F-0636, Resident Assessment and Care Planning Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 14, 2023).
No harm, with potential for more than minimal harm
Assure that each resident’s assessment is updated at least once every 3 months.
Pattern (more than a few residents). CMS level E.
Health citation F-0638, Resident Assessment and Care Planning Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 14, 2023).
No harm, with potential for more than minimal harm
Ensure each resident receives an accurate assessment.
Pattern (more than a few residents). CMS level E.
Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 14, 2023).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pattern (more than a few residents). CMS level E.
Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 14, 2023).
No harm, with potential for more than minimal harm
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.
Pattern (more than a few residents). CMS level E.
Health citation F-0761, Pharmacy Service Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 14, 2023).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Pattern (more than a few residents). CMS level E.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of March 1, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (April 14, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.