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 19 of 19 citations

  1. 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).

  2. 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).

  3. 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).

  4. 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).

  5. 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).

  6. 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).

  7. 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).

  8. 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).

  9. 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).

  10. 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).

  11. 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).

  12. 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).

  13. 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).

  14. 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).

  15. 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).

  16. 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).

  17. 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).

  18. 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).

  19. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0355, 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).

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.