| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 01/22/2025 | Complaint | 1YFT | None | None | None | NoneNone | None |
| 11/20/2024 | Complaint | J5OM | None | None | None | NoneNone | None |
| 05/15/2024 | Fire/Life/Safety | QT58 | None | None | None | NoneNone | None |
| 08/28/2023 | Fire/Life/Safety | YF8T | K0353 | D | 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
| 09/28/2023 |
| 08/28/2023 | Fire/Life/Safety | YF8T | K0918 | D | 3 | ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTEElectrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
| 11/03/2023 |
| 07/05/2023 | Complaint | EK8O | None | None | None | NoneNone | None |
| 04/13/2023 | Standard | I5F5 | F0644 | D | | COORDINATION OF PASARR AND ASSESSMENTS | 05/13/2023 |
| 04/13/2023 | Standard | I5F5 | F0645 | E | | PASARR SCREENING FOR MD & ID | 05/13/2023 |
| 04/13/2023 | Standard | I5F5 | F0690 | D | | BOWEL/BLADDER INCONTINENCE, CATHETER, UTI | 05/13/2023 |
| 04/13/2023 | Standard | I5F5 | F0698 | D | | DIALYSIS | 05/13/2023 |
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