All citations for Edgemoor Hospital

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 Edgemoor Hospital

Last standard health inspection on record

December 4, 2025

Showing 1 to 25 of 30 citations

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

    Ensure medical gas and vacuum systems have documented maintenance programs.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0907, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

    Ensure gas and vacuum piping is labeled.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0909, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

    Have power receptacles that are properly grounded.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0912, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

  4. 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 July 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2024).

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

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of July 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2024).

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

    Have simulated fire drills held at unexpected times.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

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

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

    Install corridor and hallway doors that block smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of July 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2024).

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

    Inspect, test, and maintain automatic sprinkler systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of October 22, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 15, 2021).

  10. 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.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of October 22, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 15, 2021).

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

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

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

    Fire safety citation K-0223, Egress Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

    Inspect, test, and maintain automatic sprinkler systems.

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

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

  13. 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 December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

    Install corridor and hallway doors that block smoke.

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

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

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

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

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

    Ensure proper usage of power strips and extension cords.

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

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 16, 2026).

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

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

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

    Fire safety citation K-0223, Egress Deficiencies. Inspection of July 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2024).

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

    Provide properly protected cooking facilities.

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

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of July 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2024).

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

    Properly install and monitor supervisory attachments on automatic sprinkler systems.

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

    Fire safety citation K-0352, Smoke Deficiencies. Inspection of October 22, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 15, 2021).

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

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

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

    Fire safety citation K-0354, Smoke Deficiencies. Inspection of October 22, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 15, 2021).

  21. 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 October 22, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 15, 2021).

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

    Have restrictions on the use of highly flammable decorations.

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

    Fire safety citation K-0753, Miscellaneous Deficiencies. Inspection of October 22, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 15, 2021).

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

    Ensure medical gas and vacuum systems have documented maintenance programs.

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

    Fire safety citation K-0907, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of October 22, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 15, 2021).

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

    Ensure proper usage of power strips and extension cords.

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

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of October 22, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 15, 2021).

  25. No harm, with potential for minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level C.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of July 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.