Mission Point Nursing & Physical Rehabilitation Ce

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Name

  CMS lists a new name for this home. It was MISSION POINT NSG & PHY REHAB CTR OF HANCOCK.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0656. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on August 25, 2025.

• Citation F0801. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

  CMS lists it as corrected on August 25, 2025.

• Citation F0802. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

  CMS lists it as corrected on August 25, 2025.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on August 25, 2025.

  CMS has cited this home for F0812 3 times since 2023.

• Citation F0835. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  CMS lists it as corrected on August 25, 2025.

• Citation F0865. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a plan that describes the process for conducting QAPI and QAA activities.

  CMS lists it as corrected on August 25, 2025.

• Citation F0867. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on August 25, 2025.

• Citation F0868. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  CMS lists it as corrected on August 25, 2025.

• Citation F0881. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on August 25, 2025.

  CMS has cited this home for F0881 2 times since 2024.

• Citation F0882. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  CMS lists it as corrected on August 25, 2025.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on August 25, 2025.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on August 25, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on August 25, 2025.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on August 25, 2025.

• Citation F0847. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

  CMS lists it as corrected on August 25, 2025.

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CMS lists this as a standard inspection.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on September 12, 2025.

• Citation K0321. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on September 12, 2025.

  CMS has cited this home for K0321 2 times since 2023.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on October 10, 2025.

  CMS has cited this home for K0345 2 times since 2024.

• Citation K0355. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on September 12, 2025.

• Citation K0363. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on September 12, 2025.

• Citation K0711. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide a written emergency evacuation plan.

  CMS lists it as corrected on September 12, 2025.

  CMS has cited this home for K0711 2 times since 2023.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on September 12, 2025.

  CMS has cited this home for K0712 2 times since 2024.

• Citation K0741. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on September 12, 2025.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on September 12, 2025.

  CMS has cited this home for K0918 3 times since 2023.

• Citation K0374. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on September 12, 2025.

  CMS has cited this home for K0374 2 times since 2024.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0919. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on January 6, 2025.

• Citation F0572. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Give residents a notice of rights, rules, services and charges.

  CMS lists it as corrected on January 6, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on January 6, 2025.

  CMS has cited this home for F0684 3 times since 2023.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on January 6, 2025.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Fine

  CMS changed the fine from June 2, 2022 from $336,682 to $343,856.

CMS stopped payment for new admissions from September 6, 2024, for 13 days.

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• Fine

  CMS changed the fine from December 16, 2021 from $56,398 to $57,762.

CMS lists this as a standard inspection.

Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

31 of 422 Michigan homes (7%) got a citation at the immediate jeopardy level in 2024.

• Citation F0880. Severity L: immediate jeopardy, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on September 12, 2024.

  CMS has cited this home for F0880 2 times since 2023.

• Citation F0584. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 12, 2024.

• Citation F0726. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 12, 2024.

• Citation F0730. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on September 12, 2024.

• Citation F0732. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on September 12, 2024.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on September 19, 2024.

• Citation F0838. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 12, 2024.

• Citation F0851. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on September 12, 2024.

• Citation F0881. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on September 12, 2024.

• Citation F0887. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  CMS lists it as corrected on September 12, 2024.

• Citation F0909. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

  CMS lists it as corrected on September 12, 2024.

• Citation F0700. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

  CMS lists it as corrected on September 12, 2024.

• Citation F0808. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

  CMS lists it as corrected on September 19, 2024.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on September 12, 2024.

  CMS has cited this home for F0623 2 times since 2024.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on September 12, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 12, 2024.

  CMS has cited this home for F0689 2 times since 2023.

• Citation F0942. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

  CMS lists it as corrected on September 12, 2024.

• Citation F0944. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  CMS lists it as corrected on September 12, 2024.

• Citation F0945. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

  CMS lists it as corrected on September 12, 2024.

• Citation F0947. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on September 12, 2024.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on September 12, 2024.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on September 12, 2024.

• Citation E0020. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures including evacuation.

  CMS lists it as corrected on September 12, 2024.

• Citation E0030. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on September 12, 2024.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on September 12, 2024.

  CMS has cited this home for K0291 2 times since 2023.

• Citation K0324. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on September 25, 2024.

  CMS has cited this home for K0324 2 times since 2023.

• Citation K0341. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install a fire alarm system that can be heard throughout the facility.

  CMS lists it as corrected on September 12, 2024.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on September 12, 2024.

• Citation K0346. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on September 12, 2024.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on September 12, 2024.

• Citation K0354. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on September 12, 2024.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on September 12, 2024.

• Citation K0781. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have restrictions on the use of portable space heaters.

  CMS lists it as corrected on September 12, 2024.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on September 12, 2024.

• Citation K0223. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on September 12, 2024.

• Citation K0271. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have exits that are accessible at all times.

  CMS lists it as corrected on September 12, 2024.

  CMS has cited this home for K0271 2 times since 2023.

• Citation K0351. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on September 12, 2024.

  CMS has cited this home for K0351 2 times since 2023.

• Citation K0374. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on September 12, 2024.

• Citation K0511. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on September 12, 2024.

  CMS has cited this home for K0511 2 times since 2023.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on September 12, 2024.

  CMS has cited this home for K0920 2 times since 2023.

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CMS fine of $180,775 on August 12, 2024.

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• Staffing

  Total nurse staffing reported to CMS went from 2.8 to 2.5 hours per resident per day.

• Fine

  CMS changed the fine from June 2, 2022 from $325,535 to $336,682.

• Fine

  CMS changed the fine from December 16, 2021 from $52,140 to $56,398.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

141 of 422 Michigan homes (33%) got a citation at the actual harm level in 2024.

• Citation F0624. Severity G: actual harm, isolated.

  The rule CMS cited: Prepare residents for a safe transfer or discharge from the nursing home.

  CMS lists it as corrected on June 7, 2024.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on May 29, 2024.

• Citation F0745. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide medically-related social services to help each resident achieve the highest possible quality of life.

  CMS lists it as corrected on June 7, 2024.

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• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on April 26, 2024.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on April 26, 2024.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on August 14, 2023.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 14, 2023.

• Citation F0921. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on August 14, 2023.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 14, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on August 14, 2023.

• Citation F0561. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on August 14, 2023.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on August 14, 2023.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on August 14, 2023.

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CMS lists this as a standard inspection.

• Citation E0006. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct risk assessment and an All-Hazards approach.

  CMS lists it as corrected on August 14, 2023.

• Citation E0025. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Create arrangements with other facilities to receive patients.

  CMS lists it as corrected on August 14, 2023.

• Citation K0271. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have exits that are accessible at all times.

  CMS lists it as corrected on November 30, 2023.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on August 14, 2023.

• Citation K0324. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on August 14, 2023.

• Citation K0511. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on August 21, 2023.

• Citation K0711. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide a written emergency evacuation plan.

  CMS lists it as corrected on August 14, 2023.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on August 14, 2023.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on August 14, 2023.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on August 14, 2023.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on August 14, 2023.

• Citation K0351. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on August 14, 2023.

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