Laserfiche WebLink
From:727552?475 To,8181378315$6 06106/2014 16 05 #500 P 033/073 <br /> [�EPAf�TMENT OF HEALTH RfVD HUMAN SERVICES FORtv1 APPROVED <br /> CENTERS FOR MEDIGARE $� MEDICAID SERVICES �MB NO 0938-0391 <br /> STATEMENF OF DEf1CIENG{ES (X1} PftOVtQERtSUPPLtEWCL1A {X2)MiJLTSPL�CONSTRUC730N (X3}pATE SURVEY <br /> AND PLAN OF CORREC710N IDENTIFICATION NUMBER: A.BUILDING 01-MAtPI FED COMPLETED <br /> 105658 g W�NG 05/28/2014 <br /> NAME OF PROVIDER OR SUPPIlER STREET ADDftESS,GTY,STATE,ZlP GQUE <br /> ZEPHYR HAVEN HEAL7H 8 REHAB CENT�R, INC �250AAVE <br /> ZEPHYRHILLS, F4. 33542 <br /> (X4)ID SUMMARY STATEMENT OF DEFICIENCIES ID pROVIDER'S PLAN OF CdRRECTION (X5) <br /> PREFIX {EACH DEFIClENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORFttCTNE AC i ION SHOU�D BE C.fJMPLETIpN <br /> 7AG REGlltATt7RY OR L$G IQENTIFYING fNFdRMATiON} i'AG CROSS-REFERENCED TQ TNE APPRQPRtATE onTE <br /> OEFIGIENCY} <br /> K 062 tYFPA 101 LIFE SAFETY CODE STANDARd K 062 <br /> SS=D <br /> Required autamatic sprinkfer systems are <br /> cantinuously maintained in reliable operating <br /> condition and are inspected and tested <br /> periodically. 19.7.6,4.612, N�PA 13, NFPA 25, <br /> 9 7.5 <br /> This STANDARD is not met as evidenceci by: <br /> Based on observatian and staff interview the <br /> faciiity�ailed ta ins#all and mainiain the requieed <br /> automatic sprinkler system in accordance with <br /> CMS S&G-4�-Q4, NFPA'fQ1 t2QOQ}, 19.3.5, 9 7 1, <br /> and NFPA 13, (1999), 5-13.8. <br /> Findings incSude� <br /> 1. On Q5128/14,fhe day af survey, abservatian <br /> during the concurrent interior and exterior tour <br /> from 9:45 a.m., to 1:00 p.m., accompanied by a <br /> facifity administrative ar�d a maintenance <br /> representative revealed four overhangs physically <br /> attached and extend'sng out from the buiiding 4 <br /> feet or more and not sprinklered. Staff interview <br /> of the facility maintenance representative <br /> revealed fhe four overhangs did con#ain <br /> cambustible material, (wood products), and were <br /> not sprinkEered by the a#tic sp�nkler system. The <br /> locations included, the overhang at the cou�tyard <br /> between khe Direct4r of Nursing's Office and the <br /> 3p0 corridor"Study", the averhang at the <br /> caurty�ard between the 300 corridor Dining Roam <br /> and the 200 carricior"S#t�ciy", th� �verhang at the <br /> caurtyard between the 200 corridar Living Room <br /> and the Activities Directors'O�ce on the 1 fl0 <br /> corridcar. The fourth averhang is located at the <br /> Labby exit between the Therapy Department and <br /> the 100 corridor Din�ng Raom. <br /> FORM CMS-2567(02-99)Prevlous Vsrslons Obsolete Event Ip;TLNV21 Facility ID:55111 If cOfl�lnuatiOn Sheel PBge 6 Of 8 <br />