| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 02/07/2025 | Fire/Life/Safety | 598D | K0353 | E | 3 | SPRINKLER SYSTEM - MAINTENANCE AND TESTINGSprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25 | 03/06/2025 |
| 02/07/2025 | Fire/Life/Safety | 598D | K0914 | E | 3 | ELECTRICAL SYSTEMS - MAINTENANCE AND TESTINGElectrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99) | 03/06/2025 |
| 02/06/2025 | Standard | 598D | F0694 | D | | PARENTERAL/IV FLUIDS | 03/05/2025 |
| 02/06/2025 | Standard | 598D | F0698 | D | | DIALYSIS | 03/05/2025 |
| 02/06/2025 | Standard | 598D | F0803 | D | | MENUS MEET RESIDENT NDS/PREP IN ADV/FOLLOWED | 03/05/2025 |
| 02/06/2025 | Standard | 598D | N0201 | D | 3 | RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE | 03/05/2025 |
| 02/06/2025 | Standard | 598D | ZZ814 | D | 3 | BACKGROUND SCREENING CLEARINGHOUSE435.12 Care Provider Background Screening Clearinghouse.-
(2)(b) Until such time as the fingerprints are enrolled in the national retained print arrest notification program at the Federal Bureau of Investigation:
1. A person with a break in service of more than 90 days from a position that requires screening by a specified agency must submit to a national screening if the person returns to a position that requires screening by a specified agency.
2. Effective January 1, 2026, or a later date as determined by the Agency for Health Care Administration, for the participation of qualified entities in the clearinghouse under s. 435.12, a person with a break in service of more than 90 days from a position for which screening is conducted by a qualified entity participating in the clearinghouse must submit to a national screening if the person returns to a position for which screening is conducted by a qualified entity.
(c) An employer of persons subject to screening or a qualified entity participating in the clearinghouse must register with the clearinghouse and maintain the employment or affiliation status of all persons included in the clearinghouse.
1. Before January 1, 2024, initial status and any changes in status must be reported within 10 business days after a person receives his or her initial status or after a change in the person ' s status has been made.
2. Effective January 1, 2024, initial status and any changes in status must be reported within 5 business days after a person receives his or her initial status or after a change in the person ' s status has been made.
(d) An employer or a qualified entity participating in the clearinghouse must register with and initiate all criminal history checks through the clearinghouse before referring an employee or potential employee or a person with a current or potential affiliation with a qualified entity for electronic fingerprint submission to the Department of Law Enforcement. The registration must include the person ' s full first name, middle initial, and last name; social security number; date of birth; mailing address; sex; and race. Individuals, persons, applicants, and controlling interests that cannot legally obtain a social security number must provide an individual taxpayer identification number.
| 03/05/2025 |
| 12/17/2024 | Complaint | TIKH | None | None | None | NoneNone | None |
| 08/08/2024 | Complaint | 7DXZ | F0755 | E | | PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS | 09/08/2024 |
| 08/08/2024 | Complaint | 7DXZ | N0090 | E | 3 | PHARMACY POLICIES AND PROCEDURES | 09/08/2024 |
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