Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 01G011	(X3) Date Survey Completed 10/08/2025
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 manual stop station on outside of the generator housing) FACP: Firelite ES-200X (installed 2021) 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 483.475 Emergency Preparedness for LTC facilities, as observed by the LS Surveyors 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 manual stop station on outside of the generator housing) FACP: Firelite ES-200X (installed 2021) 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 requirements of 42 CFR, Subpart 483.470 were not met as evidenced by 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 Surveyors while accompanied by the facility maintenance personnel.
E0039	EP Testing Requirements CFR(s): 483.475(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). [For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. [For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. [For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. [For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. [For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. [For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. [For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. [For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to complete the required annual testing/exercises per the requirements of: 42 CFR 483.475(d) This deficiency affects all the emergency preparedness plan. Findings include: The facility failed to conduct exercises to test the emergency plan at least twice per year. The facility must do all the following: 1. Participate in a full-scale exercise that is community based or when a community based exercise is not accessible, an individual facility based. If the facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the facility is exempt from engaging in a community based or individual facility based full-scale exercise for one year following the onset of the actual event. 2. Conduct an additional exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community based or individual facility based (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. 3. Analyze the facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the facility's emergency plan, as needed. A member of maintenance staff and administrative staff were present when this deficiency was identified. Based on review of documentation, the facility failed to complete the required annual testing/exercises per the requirements of: 42 CFR 483.475(d) This deficiency affects all the emergency preparedness plan. Findings include: The facility failed to conduct exercises to test the emergency plan at least twice per year. The facility must do all the following: 1. Participate in a full-scale exercise that is community based or when a community based exercise is not accessible, an individual facility based. If the facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the facility is exempt from engaging in a community based or individual facility based full-scale exercise for one year following the onset of the actual event. 2. Conduct an additional exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community based or individual facility based (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. 3. Analyze the facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the facility's emergency plan, as needed. A member of maintenance staff and administrative staff were present when this deficiency was identified.
KS100	General Requirements - Other CFR(s): NFPA 101 General Requirements - Other 2012 EXISTING List in the REMARKS section any LSC Section 33.1 or 33.2 General Requirements 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 observation, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.6.2.3 (11), 11.3.4.1, and 11.6.5.2 This deficiency affects 1 of 1 oxygen storage areas. Findings include: During a tour of the facility, the surveyor observed the following in the Med Gas Storage Closet at the Nurses' Station: 1. One 24 cu.ft. and two 6 cu.ft. unsecured oxygen cylinders 2. The door to the closet did not have a precautionary sign that reads: "Caution: Oxidizing Gas(es) Stored Within No Smoking" 3. The empty cylinders were not segregated from the full cylinders A member of the maintenance staff was present when this deficiency was identified.
KS168	Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING (Slow) In Slow Evacuation Capability facilities, the facility shall be housed in a building where the interior is fully sheathed with lath and plaster or other material providing a 15-minute thermal barrier, including all portions of bearing walls, bearing partitions, floor construction, and roofs. All columns, beams, girders, and trusses shall be similarly encased or otherwise shall provide not less than a 1/2-hour fire resistance rating, unless modified by the modified by the following: * Exposed steel or wood columns, girders, and beams (but not joists) located in the basement shall be permitted. * Buildings of Type I, Type II (222), Type II (111), Type III (211), Type IV, Type V (111) construction shall not be required to meet the requirements of 33.2.1.3.2 (See 8.2.1). * Areas protected by approved automatic sprinkler systems in accordance with 33.2.3.5. shall not be required to meet the requirements of 33.2.1.3.2. * Unfinished, unused, and essentially inaccessible loft, attic, or crawl space shall not be required to meet the requirements of 33.2.1.3.2. * Where the facility achieves an E-score of 3 or less using the board and care occupancies evacuation capability determination methodology of NFPA 101A, Guide on Alternative Approaches to Life Safety. The requirements of 33.2.1.3.2 shall not apply. 33.2.1.3.2.1 through 33.2.1.3.2.7 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain the interior sheathing that would provide at least a 15-minute thermal barrier per the requirements of: 2012 NFPA 101, 33.2.1.3.2.1 This deficiency affects 1 room. Findings include: During a tour of the facility, the surveyor observed in the Main Electrical Room, an unsealed penetration of multiple black, blue and white cables through an interior wall (the wall between the electrical room and Resident Toilet Room 110). A member of the maintenance staff was present when this deficiency was identified.
KS211	Means of Egress - General CFR(s): NFPA 101 Means of Escape - General 2012 EXISTING Designated means of escape shall be continuously maintained clear of obstructions and impediments to full instant use in the case of fire or emergency. 33.2.2 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain the means of escape per the requirements of: 2012 NFPA 101, 33.2.2 This deficiency affects 1 of 5 exits. Findings include: During a tour of the facility, the surveyor observed a platform wheelchair scale with ramps in the means of escape of the Tornado-Safe Corridor. A member of the maintenance staff was present when this deficiency was identified.
KS321	Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure 2012 EXISTING (Prompt) Any hazardous area that is on the same floor as, and is in or abut, a primary means of escape or a sleeping room shall be protected by one of the following means: 1. Protection shall be an enclosure with a fire resistance rating of not less than 1 hour, with a self-closing or automatic closing fire door in accordance with 7.2.1.8 that has a fire protection rating of not less than 3/4 hour. 2. Protection shall be automatic sprinkler protection, in accordance with 33.2.3.5, and a smoke partition, in accordance with 8.4 located between the hazardous area and the sleeping area or primary escape route. Any doors in such separation shall be self-closing or automatic closing in accordance with 7.2.1.8. Other hazardous areas shall be protected in accordance with 33.2.3.2.5 by one of the following: 1. An enclosure having a fire resistance rating of not less than 1/2 hour, with a self-closing or automatic-closing door in accordance with 7.2.1.8 that is equivalent to not less than a 13/4 inch (4.4 cm) thick, solid-bonded wood core construction. 2. Automatic sprinkler protection in accordance with 33.2.3.5, regardless of enclosure. Areas with approved, properly installed and maintained furnaces and heating equipment, and cooking and laundry facilities are not classified as hazardous areas solely on basis of such equipment. Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 33.2.3.2. 33.2.2.2.4, 33.2.3.2, 33.2.3.2.5 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain a hazardous area per the requirements of: 2012 NFPA 101, 33.2.3.2.4 This deficiency affects 1 hazardous room. Findings include: During a tour of the facility, the surveyor observed the Activity Closet (off of the Activity/Great Room) was approximately 65 square feet with multiple cardboard boxes and paper products and the corridor door did not have a self-closing device. A member of the maintenance staff was present when this deficiency was identified.
KS351	Sprinkler System - Installation CFR(s): NFPA 101 Sprinkler System - Installation Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section 9.7 and shall initiate the fire alarm system in accordance with Section 9.6, as modified below. The adequacy of the water supply shall be documented. In Prompt Evacuation facilities, an automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One and two Family Dwellings and Manufactured Homes, shall be permitted. Automatic sprinklers shall not be required in closets not exceeding 24 square feet and in bathrooms not exceeding 55 square feet, provided that such spaces are finished with lath and plaster or materials providing a 15-minute thermal barrier. In Prompt Evacuation Capability facilities where an automatic sprinkler system is in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, automatic sprinklers shall not be required in closets not exceeding 24 square feet and in bathrooms not exceeding 55 square feet, provided that such spaces are finished with lath and plaster or material providing a 15-minute thermal barrier. In Prompt Evacuation Capability facilities in buildings four or fewer stories above grade plane, systems in accordance with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and including Four Stories in Height, shall be permitted. Initiation of the fire alarm system shall not be required for existing installations in accordance with 33.2.3.5.6. Where an automatic sprinkler is installed, attics used for living purposes, storage, or fuel-fired equipment are sprinkler protected by July 5, 2019. Attics not used for living purposes, storage, or fuel-fired equipment meet one of the following: 1. Protected by heat detection system to activate the fire alarm system according to 9.6. 2. Protected by automatic sprinkler system according to 9.7. 3. Constructed of noncombustible or limited-combustible construction; or 4. Constructed of fire-retardant-treated wood according to NFPA 703. 33.2.3.5.3, 33.2.3.5.3.1, 33.2.3.5.3.3, 33.2.3.5.3.4, 33.2.3.5.3.6, 33.2.3.5.7 This STANDARD is not met as evidenced by: Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of: 2012 NFPA 101, 33.2.3.5.3, and 9.7 2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1 This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following: (1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating (2) General description (3) Quantity of each type to be contained in the cabinet (4) Issue or revision date of the list A member of the maintenance staff was 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 observation and review of documentation, the facility failed to maintain the automatic sprinklers per the requirements of: 2012 NFPA 101, 33.2.3.5.3, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.6 This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the facility failed to provide documentation that the (11) dry sprinklers installed in 2006, located on all porches and in the walk-in cooler had been replaced or a representative sample tested within 10 years of installation. A member of the maintenance staff and the administrator were present when this deficiency was identified.
KS700	Operating Features - Other CFR(s): NFPA 101 Operating Features - Other List in the REMARKS section any LSC Section 32.7 and 33.7 Operating Features requirements 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, the facility failed to maintain the testing of the diesel generator per the requirements of: 2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2 2010 NFPA 110, 1.3, 8.4.2, 8.4.2.3, and 8.3.8 This deficiency affects 1 of 1 generator. Findings include: During a tour of the facility, the facility failed to provide documentation on the following: 1. Testing the diesel generator: i. Once monthly for a minimum of 30 minutes under one of the following conditions: a. Operating temperature conditions at not less than 30% of the nameplate kW rating b. Loading that maintains the minimum exhaust gas temperature OR ii. Provide an annual 1.5-hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours. 2. To have a fuel quality test performed at least annually using tests approved by ASTM standards. A member of the maintenance staff was present when this deficiency was identified.