Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 01G011	(X3) Date Survey Completed 08/17/2022
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, with remote maual stop station) FACP: Simplex 4010 (installed 2007) Locking Devices: 15 Second Delayed Egress (all doors except kitchen exterior door) Smoke Detection: Corridor Beds: 16 Census:15 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 in compliance with 42 CFR 483.475 - Emergency Preparedness for ICF/IID facilities, as observed by the LS 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, with remote maual stop station) FACP: Simplex 4010 (installed 2007) Locking Devices: 15 Second Delayed Egress (all doors except kitchen exterior door) Smoke Detection: Corridor Beds: 16 Census:15 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(j) - ICF/IID as evidenced by the the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by facility personnel.
KS222	Egress Doors CFR(s): NFPA 101 Egress Doors 2012 EXISTING (Prompt) Doors and paths of travel to a means of escape shall not be less than 28 inches. Bathroom doors shall not be less than 24 inches. Doors are swinging or sliding. Every closet door latch shall be readily opened from the inside in case of an emergency. Every bathroom door shall be designed to allow opening from the outside during an emergency when locked. No door in any means of escape shall be locked against egress when the building is occupied. Delayed egress locks complying with 7.2.1.6.1 shall be permitted on exterior doors only. Access-controlled egress locks complying with 7.2.1.6.2 shall be permitted. Forces to open doors shall comply with 7.2.1.4.5. Door-latching devices shall comply with 7.2.1.5.10. Corridor doors are provided with positive latching hardware, and roller latches are prohibited. Door assemblies for which the door leaf is required to swing in the direction of egress travel shall be inspected and tested not less than annually in accordance with 7.2.1.15. 33.2.2.5.1 through 33.2.2.5.7, 33.7.7, 42 CFR 483.470(j)(1)(ii) This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain the required delayed egress exit door signage per the requirements of: 2012 NFPA 101, 33.2.2.5.5.1, and 7.2.1.6.1.1 (4) This deficiency affects 1 of 2 smoke compartments. Findings include: On 08/17/2022, during a tour of the facility from 8:30 am to 3:30 pm, the surveyor observed the following delayed egress doors were without the required signage; "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPEN IN 15 SECONDS": 1. The Front Lobby door 2. The North Corridor door A member of the maintenance staff was present when this deficiency was identified.
KS345	Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance 2012 EXISTING (Prompt) A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of: 2012 NFPA 101, 33.3.3.4.1, and 9.6.1.3 2010 NFPA 72, 14.4.5.3.2 This deficiency affects the whole facility. Findings include: On 08/17/2022, during a tour of the facility from 8:30 am to 3:30 pm, the facility failed to provide a smoke detector sensitivity test report completed within the past two years. The facility failed to provide any documentation of conducting a smoke detector sensitivity test in the past. A member of the maintenance staff was present when this deficiency was identified.
KS352	Sprinkler System - Supervisory Signals CFR(s): NFPA 101 Sprinkler System - Supervisory Signals 2012 EXISTING (Prompt) Where a required automatic sprinkler system is installed, supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility, when sprinkler operation is impaired. An automatic sprinkler system in accordance with NFPA 13D would not require water flow alarms where a facility has smoke alarms or smoke detectors in accordance with NFPA 72. 9.7.2.1, 7.6 (NFPA 13D), NFPA 72 This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to provide the code required tamper switch (electronic supervisory signal) for the automatic the sprinkler system per the requirements of: 2012 NFPA 101, 33.2.3.5, and 9.7.2.1 2010 NFPA 72, 10.7.4, and 10.16.2 This deficiency affects the whole facility. Findings include: On 08/17/2022, during a tour of the facility from 8:30 am to 3:30 pm, the facility failed to maintain the existing noncode approved tamper switch for a valve in the sprinkler pit. The existing plug-in-type tamper switch was deteriorated and inoperable and not able to be plugged in to the switch box. A member of the maintenance staff and the administrator were present, when this deficiency was identified.
KS353	Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing 2012 EXISTING (Prompt) NFPA 13 and 13R Systems All sprinkler systems installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, are inspected, tested and maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection System. NFPA 13D Systems Sprinkler systems installed in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, are inspected, tested and maintained in accordance with the following requirements of NFPA 25: 1. Control valves inspected monthly (NFPA 25, section 13.3.2). 2. Gauges inspected monthly (NFPA 25, section 13.2.71). 3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6). 4. Alarm devices tested semiannually (NFPA 25, section 5.3.3). 5. Valve supervisory switches tested semiannually (NFPA 25, section 13.3.3.5). 6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1). 7. Visible pipe inspected annually (NFPA 25, section 5.2.2). 8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3). 9. Buildings inspected annually prior to freezing weather for adequate heat for water filled piping (NFPA 25, section 5.2.5). 10. A representative sample of fast response sprinklers are tested at 20 years (NFPA 25, section 5.3.1.1.1.2). 11. A representative sample of dry pendant sprinklers are tested at 10 years (NFPA 25, section 5.3.1.1.15). 12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4). 13. Control valves are operated through their full range and returned to normal annually (NFPA 25, section 13.3.3.1). 14. Operating stems of OS&Y valves are lubricated annually (NFPA 25, section 13.3.4). 15. Dry pipe systems extending into unheated portions of the building are inspected, tested and maintained (NFPA 25, section 13.4.4). A. Date sprinkler system last checked and necessary maintenance provided. __________________________ B. Show who provided the service. _________________________ C. Note the source of the water supply for the automatic sprinkler system. __________________________________ (Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.) 33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to provide all of the quarterly automatic sprinkler inspection records for the past 12 months per the requirements of: 2012 NFPA 101, 33.3.3.5.1, 9.7.5, 9.7.7, and 9.7.8 2011 NFPA 25, Table 5.1.1.2 This deficiency affects 3 of 4 quarterly inspections. Findings include: On 08/17/2022, during a tour of the facility from 8:30 am to 3:30 pm, the facility failed to provide all of the quarterly automatic sprinkler inspection records for the past 12 months. Only one report dated 06/23/2022 was provided. A member of the maintenance staff and the administrator were present when this deficiency was identified.