| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01G011 | (X3) Date Survey Completed 06/20/2019 |
| Name of Provider or Supplier Rainbow Omega, Inc, | Street Address, City, State 202 Hope Drive, Eastaboga, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| E0000 | K3 Building: 0101 K6 Plan Approval: 2006 K7 Survey Under: 2012 Existing K8 ICF/IID Small Generator: One Diesel, Katolight 125 kW (installed 2007) FACP: Simplex 4010 (installed 2007) Locking Devices: None Smoke Detection: Corridor Beds: 16 Census:16 Type of Structure: 2006 one story unprotected wood frame, Type V(000). The facility has a complete automatic sprinkler system with a sprinkler pit. The facility is surveyed under impractical to evacuate. During a routine recertification survey conducted on this date, the facility was found to be not in compliance with 42 CFR 483.475 - ICF/IID Emergency Preparedness for LTC facilities, as observed by the LSC Surveyor while accompanied by facility personnel. |
| K0000 | K3 Building: 0101 K6 Plan Approval: 2006 K7 Survey Under: 2012 Existing K8 ICF/IID Small Generator: One Diesel, Katolight 125 kW (installed 2007) FACP: Simplex 4010 (installed 2007) Locking Devices: None Smoke Detection: Corridor Beds: 16 Census:16 Type of Structure: 2006 one story unprotected wood frame, Type V(000). The facility has a complete automatic sprinkler system with a sprinkler pit. The facility is surveyed under impractical to evacuate. During a routine recertification survey conducted on this date, the facility was found to be not in compliance with 42 CFR 483.470 - ICF/IID as evidenced by the NFPA 101 Life Safety Code (LSC) and codes referenced by the LSC, as observed by the LSC Surveyor while accompanied by facility personnel. |
| KS500 | Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 32.2.5 and 33.2.5 Building Services that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This STANDARD is not met as evidenced by: Based on review of documentation and interview, the facility failed to maintain the diesel generator fuel per the requirements of: 2012 NFPA 101, 33.2.5, and 9.1.3.1 2010 NFPA 110, 1.3, and 8.3.8 Findings include: On 06/20/2019, during a tour of the facility from 9:00 am to 12:00 pm, the facility failed to provide documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards. A member of the maintenance staff was present when this deficiency was found. |