| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 03/28/2024 | Standard | FU1S | CZ814 | | U | BACKGROUND SCREENING CLEARINGHOUSE | 04/28/2024 |
| 03/28/2024 | Standard | FU1S | F0689 | G | | FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES | 04/28/2024 |
| 03/28/2024 | Standard | FU1S | N0201 | G | 2 | RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE | 04/28/2024 |
| 03/28/2024 | Standard | FU1S | N0915 | D | 3 | ADVERSE INCIDENT | 04/28/2024 |
| 03/27/2024 | Fire/Life/Safety | FU1S | K0324 | E | 3 | 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
| 04/28/2024 |
| 03/27/2024 | Fire/Life/Safety | FU1S | K0521 | F | 3 | 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
| 04/28/2024 |
| 03/27/2024 | Fire/Life/Safety | FU1S | K0914 | F | 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)
| 04/28/2024 |
| 03/27/2024 | Fire/Life/Safety | FU1S | K0920 | F | 3 | ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENSElectrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 | 04/28/2024 |
| 08/10/2023 | Fire/Life/Safety | 6XZK | None | None | None | NoneNone | None |
| 04/11/2023 | Complaint | 800S | F0684 | E | | QUALITY OF CARE | 05/11/2023 |
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