Survey Date | Inspection Type | Track ID | Deficiency | Requirement Description | Correction Date |
10/17/2024 | Complaint | LP6Q | None | NoneNone | None |
04/12/2024 | Complaint | XK18 | H0030 | EMERGENCY CARE - SIGNAGE REQUIREMENTS | 06/06/2024 |
04/12/2024 | Complaint | XK18 | H0033 | EMERGENCY CARE - TXFR PROC WRITTEN CERTIFICAT | 06/06/2024 |
04/12/2024 | Complaint | XK18 | H0040 | EMERGENCY CARE - EXEMPTIONS | 06/06/2024 |
04/12/2024 | Complaint | XK18 | H0043 | EMERGENCY CARE - EMERGENCY SERVICES PERSONNEL | 06/06/2024 |
12/21/2023 | Fire/Life/Safety | 4RZE | K0324 | COOKING FACILITIESCooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2
| 02/23/2024 |
12/21/2023 | Fire/Life/Safety | 4RZE | K0353 | 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
| 02/06/2024 |
12/21/2023 | Fire/Life/Safety | 4RZE | K0355 | PORTABLE FIRE EXTINGUISHERSPortable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
| 12/29/2023 |
12/21/2023 | Fire/Life/Safety | 4RZE | K0521 | HVACHVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
| 12/29/2023 |
12/21/2023 | Fire/Life/Safety | 4RZE | K0907 | GAS AND VACUUM PIPED SYSTEMS - MAINTENANCE PRGas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
| 12/22/2023 |
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