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From�727552147� To 81813783158G 06106/2014 16 06 #500 P.034/073 <br /> vcrr�rt�atcsv i vr ncr-ti��t-�r���v nv�vir��v �crtvtt.c� t-C1FtN1 At'Nt�UV�L} <br /> CENTERS FOR MEDICAR�& MEDICAID SERVICES OMB NO. Q938-0391 <br /> STATEMEt�FT`QF[3E�SCIEtJGIES (X'!} PROVIOERJSUPPG1Et:ICLIA {X2)MU�TtPIE COfJSTRUGTfON (X3}DATE SItRV£Y <br /> AND PLAN QF CORRECTION IDENTIFlCA710N NUMBER A BUILDING Oi•MAIN FED COMPLETED <br /> 105658 a.w�N� 0512$J2014 <br /> NAME OF PROVlDER OR 9UPPUER STI�ET ADDRESS,CITY,STATE,Z�R CODE <br /> ZEPHYR HAVEN HEAL.TH 8�REHAB CENTER, INC 38250 AAVE <br /> ZEPNYRHILLS,FL 33542 <br /> (X4)ID SUMMARY STA`fEMENT OF DEFIGlENCIES �p FR�VIDER'S PLAN OF GORRECTldN <br /> PREFIX (EACH DEFIGIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CqRRECTIVE ACTION SFIOULD D[ C01.�a�ETIpM <br /> TA� REGULATORY OR L.SC IDEN7'IFYING INFOF2MATtON) TAG CROSS-REFERENCED TO THE APPRpPRIATE DATE <br /> DEF1G!ENCY) <br /> K t}62 Continued Fram pac�e 6 K 062 <br /> 2. On fhe day of survey the facility census was <br /> 111 residents. <br /> GMS S&C-09-Q4 <br /> NFPA 101 (2000), 19.3 5, 9.7.1 <br /> NFPA 13, (1999), 5-13 8 <br /> References: <br /> CMS S&C-09-04. On August 13, 2008, the <br /> Genters for Medicare 8� Medicaid Services(GMS� <br /> pubiished a final rule entit(ed "Medicare and <br /> Medicaid Programs; Fire�afety Requirements for <br /> Long Term Care Facilities,Automatic Sprinkler <br /> Systems " This regulation requires all long term <br /> care#acilities to be equipped with a supervised <br /> automatic sprinkler system byAugust 13, 2013, <br /> instafied in accordance with the 1999 edition af <br /> the National Fire Protection Assaciatian's <br /> (NFPA) "Standard for the Installation af Sprinkler <br /> �ystems" (NFPA 13�. <br /> NFPA 101 (2000), 19.3 5 Extinguishment <br /> Ftequirernents 19.3.5.1 Where required by <br /> 19.1.6, health care facilities shall be pratected <br /> thraughaut by an approved, supervised automatic <br /> sprinkler system in accordance with Sec�on 9.7. <br /> NFPA 101 (200fl),9 7.1 Automaiic Sprinklers. <br /> 9 7.1.1"` Each automatic sprinkler system <br /> required by anather section of this Code shail be <br /> in accordance with NFPA 13, Standard for the <br /> Installation of Sprinkler Systems. <br /> NFPA 13,(1999), 5-13.8*Exterior Roofs or <br /> Canopies.5-13.8.1 Sprinklers shaii be i�stailed <br /> under e�erior roofs or canopies exceeding 4 ft <br /> (1.2 m)in width. F�cception:Sprinklers are <br /> permitted to be omittec�where the canapy or rorrf <br /> is of noncombustible or limited combustible <br /> construction. 5-13.8.2`Sprinklers shaSi be <br /> FORM GMS-2587(o2-sa)Previous versons Obsolete Event IO:TLNV21 FaclCrty ID:55111 If continuation sheet Page 7 of 8 <br />