| Survey Date | Inspection Type | Track ID | Deficiency | Requirement Description | Correction Date |
| 12/27/2018 | | 8E87 | None | NoneNone | None |
| 08/09/2018 | Complaint | ET4M | None | NoneNone | None |
| 08/09/2018 | Complaint | R94P | None | NoneNone | None |
| 07/11/2018 | Complaint | DNI6 | None | NoneNone | None |
| 07/11/2018 | Complaint | POXU | None | NoneNone | None |
| 05/18/2018 | Complaint | 5E4X | None | NoneNone | None |
| 05/18/2018 | Complaint | RQJ4 | None | NoneNone | None |
| 02/02/2018 | Fire/Life/Safety | T6SM | 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
| 05/02/2018 |
| 02/02/2018 | Fire/Life/Safety | T6SM | 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
| 05/02/2018 |
| 02/02/2018 | Fire/Life/Safety | T6SM | K0921 | ELECTRICAL EQUIPMENT - TESTING AND MAINTENANCElectrical Equipment - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 (NFPA 99)
| 05/02/2018 |
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