M31, 2014 0TPM | EFFCU PINES HIATUS Ne 8117. PRINTED: So DEPARTMENT OF HEALTH AND HUMAN SERVICES FORMAPPROVED Mi a, ‘Be UCTIPLE CONSTRUCTION {32 DATE SURVEY ‘A BADING Of MAIN FED ommvere NG szinizo TARESE PROMDER OR UPPER “STREET ABDRESS, GAY, STATE ZP COE ‘sa90m asTH AVE HOLLYWOOD HILLS REHABILITATION CENTER, LLC HOLLYWOOD, FL 9021 SUMMARY STATEMENT OF DEFICIENCIES 7» | PROVIDERS PLAN OF CORRECTION t Wal coURP RNa | nbn Desa | oo aa | eexcconneonie ‘OR USC IDENTIFING MEORMATION) ACEEREFERENCRD TT APPROPRIATE i ‘K 000 | INITIAL COMMENTS. ! K0001 | i | | 42.CFR mame (0) ! {7 Survey Under; 2000 Existing | [RE SNENF + An unannaunced Recertification survey was ‘conducted at Holywood Hills Nursing Home in Holywood, Focéa on 2014 te | WUINNNTIENL 2014. Deficiencies were identified j 3 6 rbsul ofthe recerifcation survey. The clit i natin compliance wih te regulations at | |42.CER Par 483, Requirements forLong Term | | Care Facities. This ennual survey was : | conducted to determine the feciy's compliance. | i ‘wi the NEPA Life Safety Code (LSC) 108 (2000) | including ll Chapter 2 referenced cedes, and | | erenced standords end pubficatons as i \ *rmandiated by the Center for Medicare and | Medicaid Services (CMS). At the entrance | | onfarence the facity did not formally advise of | | electing any LSC categorical waWers allowed | $8: MINN dated SURRNIIEM 2013. ! The facility as surveyed was built o oensed in| » 1964 witha building changes i 1972 and 1989, { : Building may be of Type (11) constuction. 40 | | story, 152 bed nursing home an has (10) stoke | | compartments, Buiding features and protection “nei a complete supervised fire alarm system, | .ompleteavorat fre per est and 2 Hemporary erator. The building is | connected to @ Hospital and shares al) | ite safety features including fre alarm, sprinkler | and generator systems. The facity Admiistrotor ‘indicted there are no Fire Safety Evaluation ‘System (FSES) or walvers, Administration A REPRESENTATIVES SIGNATURE SORTER Mrvaishatoy tafirfeon in iam ta Ty ST aera A aT oma To ng TST sor other apeguards provide -iplacon eb pian (ote nelwesoe) Except for nursing homes, the findings staiad above ore discicrable 9 days Soe tean ee a eta ronnie th ccuratta Woeranawiad ciawsteoesmne some ae ee ee ee ee en era wanted Some FOR NNN Pros verte Chale vere 26nc2) Fasiy 005 ‘Weoniouaton shest Page 1 of 41. W)t4 TATPM EFECU PIRES HIATUS | DEPARTMENT OF HEALTH AND HUMAN SERVIOES PERM APPROVED AID SERVICES: 1B. TsareNeNror cercKNcEs [ax PROvERAUerLeRciA [8 MLLTALE CONETAUOTION ORR oF coMmeTON SoerreMTONNOMBER |. agua Of HAN FED sosozs wns ‘NAGE OF PROVIOER OR SUPPLIER ‘STREET AGORESS, CITY, STATE, ZP CODE swao aeTA A, HOLLYWOOD HILLS REHABILITATION CENTER, LLC HOULYwooo.#L ss021 x8 Sima son or OEnENCES Toe oF coRRETTION Tom, FRR | sacoercincy most oe precenen be Fu, men | tenteerecwencrin wanes | capi “ho” | AEGLUATORYORTSDIOENTINING WORST =| TRO Siafeneamarnae |S i L i | — 1 000; continued Frem cage 1 K 000) i indigated that no conetruction cr modifeations | t ‘were made tothe bulding since last years survey’ i j {which would ehange the orginal approved | | | building blueprint pans. On the date of survey | | the factty was notable to provide blue pelts of | | ! ‘he faclty constuction. Special features ofthis | “acy include sharing the bung wih @ | UMN Hospital and having a temporary | I evergncy gover fr 8 rumba of ear, i { including last years survey. Resident 1 i count chack was dene, i | | ‘Based on the findings ofthis survey, this tacity is i notin compliance with NEPALSC (2000) Existing | Life Safely Code and referenced standards and : i pubicafions as mandated by the Center for | | Medicare and Mediceld Services. (CMS), The | ! Holiowing deficiencies were cited as K tags as | | + result ofthese areas of non-compliance: | | KO1Z/NFPA101 LIFE SAFETY CODE STANDARD «=| K 012 -D12- Life Safety Coe Standard. fire wall 0474472015 : separations i * Bulging constuction type an height meets one | ofthe flowing. 18.162, 18:1. Fee stopping materials (34) wil be reappliog idliciore Wea USS Tag” | i teem cce eS ! Uc penetraton dota to al areas where i Tee veppavatuore ware coaered. | : Tne Ut ted co! vas fr ach peta | i | el aes maar ed epetbow | fine 35 boon used ins | This STANDARD js nol met as evidenced by: | [eorescemtn he Ute Sd Pooks | j Based on observation, witien document review, | lve attached) i {and staff interview, the facilty faled to maintain I . } the building fre wal separations. This deficient |2.The Diwiot of Ergmoaing! designee wit ‘ practice affects ail smoke compartinents, staf, | conduct BENIN rounds to sesess ait _ Mrs anda esters, Te fait hs tne ‘amok bari for smlarconcems : capacity for 152 beds and atthe tre of survey | j 3. Aprevontve maintenance schedule wit be fecanut vas ot Secee chceeefeteg ee | ane ‘neue, | neler edwin re ca Oro NN Pros Were Oboe Ee OE Fay rot Treantnuaion chest Page 2oft4M31, bid tc 01PM | EFFCU PINES BIAT! DEPARTMENT OF HEALTH AND HUMAN SERVICES _GENTERS FOR MEDICARE & MEDICAID SERVICES, JsTreNeNt or oenences {tn eROVDERSLPPUERICUA [AIO PLAN OF CORRECTION ‘DENTERATION NUMBER: 405024 US Mo 4611 fi PRINTED: 12/10/2014 FORM APPROVED NO aa (Ba) MITE CONSTAUETON A.BLDING OT - MAN FED wns, oat Sve I" coumcereo sanisr201g THE GF PROVIDER OR SUPPER HOLLYWOOD HILLS REHABILITATION CENTER, LLC FREET ADDRESS. GY, STATE CODE +00 N3ETH AVE HOLLYNOOD, FL 33021 ane | “Sanaa STATEMENT oF DEFENCES Setex | (eacwoenoecy WusT gE PRECEDED ay FULL TAG | REGULATORY 08 LSCICENTIFING INFORATION) a rE He 7 PROUDERS Pu GF SORAECTON 33, ACTOR SHOUD ee | COMRETON sADHCOR ‘DERIIENCY) 0123 Continues From page 2 | On MORAN HEBEL 2074 between 8:20 a.m. ‘and 4 pm., accompanied by the Matntenance | Diraotor during te observation tour itwas noted “that there were improper and/or unsealed fre-stop penetrations observed, Examples include but are not nite othe following: (1) nat feast 2-6 areas where piping through the fio wall, fire-stop material coourrd inthe fre _ walls above fre doors in fre compartment | division wali, (2)'n a east 4 aroos winere piping through the fire weil, fire-stop material occusred in the aif ‘handier| fie wall. {@) In at east 2 areas where piping threugh the abave the communications mma | (2) In at least 6 areas where piping through the | fire wall, fite-etap material ocourred in the ‘Hlammable iquid storage MAI wal | (8) In at least 3 seas where piping through the | fre wall fee-stop material occurred inthe main ‘electrics! NE wal Improper fire stopping voids a fre barter rating _a3 is considered a z30 Nour rating, An {terviw with the maintenance director atthe | ime of observation(s) ravealed he could not | produce any type of documentation showing the | ye stopping was installed per the manufactures | Specifications forthe fre walls, No | documentation of resting manufacture 4 specifications, ULornationaly recopnized | products to seal the hole penetrations tothe fre wat, fre-stop material oocurred i the fire wail i i 1 KOt | ! | | _ OR NPs re Orne oat RG i RECTIE, | CAOSBREFERENGED TO THEAPPROPRATE DATE { L i2l4, altindings willbe reported by the | oN/112015 | Maintenance Director or his designee fo |the Quaity Assurance commites on ts ‘monthly meeting and will be mantered by rounds. | L Feiny racer |the QA committe for the next three ‘months, and semi-annually thereafter. i \ 5 The Admins! degree wi "oduct quay and gm-annuel | i ‘Weoninoaton sheet Page of 14M3). 2014 1:02PM EFFCU PINES HIATUS Mo bit PA PRINTED: SV FORM APPROVED OYE NO (Cea MbcTeLR cousTAUETION Joy pare survey. A BRILOING C1 - MAIN FED commen 2G, sansin0t8 THaie OF ROMER OR BOPPLER HOLLEWOOD MILLS REHABILITATION CENTER, LLC “STREET ADDRESS, CHV, STATE, DP CODE DON ASH AE HOLLYWOOD, FL 99021 ‘UMmARY Sia EUaaT OF DERDINCES (AGH DEFICENGY AUST BE PRECEDED BY FUL REGUSATORY OR LC DENT YRS RFORBIATION, oom PREF Ae Kore, Continued From page 3 “require fie baie ratings were povided. No “dione writen documentation t suppor the ire rated protection by re-stoping ofthe | fte-stop penetrations was provided atthe time of ext. |:The consus was verifed by he Administrator, |The findings were acknowledged by the : Administralor and was verified bythe | Meintenance Diector at the ime of observation [ed atthe ont conference on AA 204 | Actual NEPA Standards: | NEPALSC 105 (2000) 19.4.6, 8292.42, {8.2.46, and 8.2. - Penetration opening | protectin. NFPA LSC 10% (2000) 18.3.7 and 148.8 Conditons for oocupancy. NFPA 101 LSC (2000) 8.2.3.2.4.2 requires pipes, conduits, bus MRM cables wires, ait MAMI pneumatic ME and INMIL ond siniar bulging service that pass | trough fre batiers shall be protected ..need | documentation of meeting NFPA 264 standard | methods of fasts offre endurance of bulding | construction and materials, a¢ pat ofa rated | assembly. Protection fs 0 be by 8n approved {hrough penetration system that has been tested tests of hrough-penetration fre stops, NEPA 1 § {2000 7-14 The authority having jurtsletion shal have the authoriy te require that shop drawings fora fire rotecuon systems be submitted for | review, snd approval and permit be issued for | instalation, rehabiitation, oF modification, K016/ NFPA 101 LIFE SAFETY CODE STANDARD 36-7 | Interior nish for maamm end spaces not used for {In accordance wih ASTM E 814, Methods for fre | tL ! ' 5K O16 NFPA 101-LSC tame spread K O18; i coeeg rating —————arescentrrers ret raat Fay ar ‘Weanunuaton sheet Pago 4 of 1«MMS. 2014 1:02PM -EFFCU PINES HIATUS No 4811 PID PRINTED: SR FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES. (2) MUCTALE cONETRUETION Avo aw OF eoRnEeTION ‘A BURLING Of - MAIN FED ave, aanaeore TOF REDE CA SUPPER ‘STREET ADDRESS, CY, TATE EP EOE ‘WON aoTH AVE HOLLYWOOD HILLS REHABILITATION CENTER, LLC HOLLYWOOD, FL 53524 TS saree or BERCES "PROVDERS FON OF Connacmion 7 Ke, .oeRene, | nix | ghee [ode “AS: REGULATORY OR SC DeNTarNG FORMATION, — | "Tag | GROEREFERENGED TO THE APPROPRIATE \ | SDT | ! ' O15 Continued From page 4 O15) the closet dots, 36 out of 10 mam ic the ft 01 {corridors or exltway, including exposed interior oor and 21 out oF 2 mmm inthe second =) | surfaces of bucings such as fixed or movable | | hoor, witb removed anda set-contaned | ‘wale, parbtions, columns, and celings, has a j wardrobe wil be instal insige the niche, (lame spread rating of Cass Aor Class B. (in) | uiy sprinkiared buldings, fame spread rating of | Olas A, Class B, oF Class C may be continued in | vse within mmm separated in accordance with 183, from the access corridors) 19.3.3.4, 1332 | i | | | This STANDARD is not met as evidenced by. i | Based on observaion and eal nerve, he : “foe fled to malta the fame spread ratings ' | _forvarious interior fishes the facily. This | | “deter ace lc a moka | | compartments, staf vihors and al residents, ! |The acy has the cepacty for 152 bed [the time of survey the census was 134, | i | i { att _ Tending nt (Cn RAN FENN 2014 Detween 8:20 a.m. |/and4 pm, accompanied by the Maintenance | | Director during the ebservatin tour was noted _ tate tally hes untae pag fltng pal "ype doors on the resident i Sbsets were adn Spprtraey 9 ou of 39 i ‘nthe fist floor end 21 oul of 30 mam ‘nthe second flor. When requested, writon | documentation ofthe fame spread ratings were | not produced by the facility, The use of un-rated {interior fish that do not mest the required fame spreed raings could generale excessive IMME srnoke, quichy spread fre, and endanger ‘¢cupants inthe event ofa fre.” An interview was | 1 Lo ccondusted at his time withthe Meintenance i i FORM HS AAT c09m Proes raons OB > Beebo Fay 06 ‘Weanlrvation sheet Page 6 of 14WES), 2014 5:00PM DEPARTMENT OF HEALTH AND HUMAN SERVICES EFFCU PINES HIATUS Me. 4811 . t Tecnu ws vate ye amit | The findings were | Administrator and verified ye Matenance . Director at the time of observations and at the exit! ‘eontererce 07 NN 2014 | Actual NFPA Standards: NFPA.LSC 101 (2000) MMMM oF 21.3.3.1, which + requires commptsnee with the requirements of (WRN 10.2 interior Fini. {018 NFPA 101 LIFE SAFETY CODE STANDARD SSF: Doors protecting conidar openings in otter than | equled enclosures of vertical openings, exts, or | hazordove areas ere substantial doors, Such a8 “those construced of 1% inch soli-bonded core | wood, or eapable of essing fe fora east 20 | minutes. Doors in spinkiered buildings ere only ‘eguired to rest he pastage of smoke, There) | no impediment to the closing ofthe doors. Doore | ‘re provided wit a means suitable for keeping iseumnieers Duten doors mestng 188.696 | ave permitted. 193.63 | Role etches are prohibied by CMS regulations {iat heath cae facies. \ ! i | K 018 |K.018- NFPA 101- LSC 2009 ~Coridor Doors Allthe doors observed not to tatch automaticaly and not functioning prenerty a the locks replaced, | The other doors, including the laundry | RORBEUNBEL wore assessed and were repaired by an outside company (Big Lock | end Key). (Pease soe atiachod invoice) |The Dros of Engineering (Maintenance) | will regularly aseess es part ofa preventive maintenance schedule, el fre doors during fire dis, Pholos are etached, | Tho Administrator / designee wi spot | eneck at doors on a monthly baste, then | ately hreater, to ensre compliance ‘Ba MURTPLE CONSTRUCTION co oare uve 2. SURDNGO- MAIN FED a s0s20 14, iE TF OORT TARRY ADORESE, Gt SATE DP CODE ‘meow STE HOLLYWOOD HILLS REHABILITATION CENTER, LLC HOLLYWOOD, FL 39021 mm ‘ilany Sata + barca T 2 FROVGERS Pa GF CORMECTION %, iCNOY HUST be PeceDED BY 1 qeoicomectvescrousnpose | comsson "Ho | SeGUMTOWoNLEtcememencomTON | ASN ofebSnarenniceDoneArmomae | OME K015| Continued From page 5 Kors) Director who acknowledged thal the tacitly could | | not produce documentation of the flame spread | |i, | | FOR I Pesce iris One Ean Facey Dee Weontnuaton sheet Page ©01143h 2014 1:02PM EFFCU PINES RIATUS DEPARTMENT OF HEALTH AND HUMAN SeRviCES HOLLYWOOD HILLS REHABILITATION CENTER, LLC 105021 Bava, ‘ba MULTIPLE CONSTRUCTION A BULDING 01 - MAM FED “STREET ADDRESS, CTY. SURE DP CODE 1200 N 36TH AVE HOLLYWOOD, FL 98021 No 4811? ae Par “Samay STATENS eFCmTCRES (GACH DEPCIENCY MAST BE PRECEOED UY FULL REQUUATORY O80 DENTIEVING INFORMATION) ade y 3 BROMDERS PLAN OF CORRECTION 018 | Continued From page 6 ‘This STANDARD Is not met as evigenced by: | Based on observation end staff interview, the “fact fet aka the biking do" opening ‘assembles. This defcient practice affects a {Smoke compartments, staf, vistors and al ‘residents. The faclity has the eapecity for 182 | beds and at the time of survey the census was 134 i The facings incude: [On DONE MN 2014 between 8:36 2.m. ‘and 4 p.m. accompanied by the Maintenance 2 Director during the observation tour twas noted) | thet when tested, various corridor doors did not | | closa and lstch inthe door frame, Doors did not | meet the code requirement of providing @ means sultble to Keep the door closed. The door ais | nat atch closed in the door frame andor the door | tothe door frame has an opening vbich wl the spread of smoke through the door. Somme | examples include bi are not fied to: | (1) Laundry MORK 3 ij (2) The fist for East activity I door, (3) Kitchen to certidor door, 114) Fle floor smoke compartment doors times 3. | _povterion wes concn at wn te ith | the Maintenance Director who acknowlodgad ard | witnessed tha! the corridor doors did not meet the | code requirement of providing a means sultable | 10 keep the door closed. No additional written | cocumentation fo suppor the testing ofthe doors | |r function or providing a smake barrier was | provided at the tie of ext FOR RR Prov Vestn Core Brewioasoat Kore Pooky ose Teoninwaion sheet Page 7 oF 14MMM 6. 2015 1:49PM EFFCU PINES HIATUS Ko, 4988 PD RNS: DEPARTMENT OF HEALTH AND HUMAN SERVICES: FORM APPROVED | _-CENTERS FOR MEDICARE & MEDICAID SERVICES NO. Fare oF DenceNeEs Jorn PROVOERSUPRUERCLA | aR MALNPLE GONSTRUETON rs) para ave sno ran oFeSenceroN Beviresnomomee | TRS Nat wan red Sours 105024 ByaNG, A2rti2044 EOF ROTOR OR PLR TaEET ATEN CIV TE POE +90 NaeTAAvE HOLLYWO00 HILLS REHABILITATION CENTER, LLC HOLLYWOOD, FL 99024 “Sinmany siaTeveNT Gr oereNGEs | pacuoencekcy src preceneDaycas | REGULATORY OR US IDENTIFYING INFORDATION) i gon PRET wo 7% oreo Tas T__PROWOERS pan oF CG@RRETON Tra (GACHCORRECTIVE ACTON SHGULD GE | COMM enoseREFERINCED To EAPPROPAITE | OAT 018: Continued From page 7 ‘The census was verified by the Administrator, | ‘The findings were acknowledged by the ‘Administrator and vorifed by the Maintenance | Director al the time of observation and atthe exit conference on A 2974, | Actual NFPA Standards: i | { NFPALSC 101 (2000) 9.3.2.4 and 19-3.6.3.2, | | NFPA 1 (2000) 54.1 installation and maintenance | ofassemblies and devices used to protect | openings n wal, floors, and celings agamet he | | spread offre and smoke within, ino, oroutof | ! buildings. NFPA.BO, coridor doors to be provided. { witha means suitable for keeping the door closed 082: NFPA 101 LIFE SAFETY CODE STANDARD SSF, | Required automatic sprinkler systems are = continuously maintained in raiable operating | condition and are inspected and tested | pedal 48.7.8, 46MM NFPA 13, NFPA26, | ‘This STANDARD not metas evidenced by: 5 Based on observation, end sisfinterview, me “oct foiled to maintain the Building automatic fie sprinter system to code requirements, This deficient practice attects all smoke compartments, staf, ators and al residents ‘The faciy has the capaciy for 182 beds and at ‘the time of survey the census was 134, 1 The findings include: Ko18 | | t 062! K-082- NFPA 101 Life Safety Standard- | ‘automatic fire sprinkler system. : ‘The closet doo, inclusing the shelf and_| the fod, willbe removed, A selt-containes wardrobe wit be installed tnaide the niche. When tis work is ‘completed, the wardrebes wi nol require ‘sprinklerng in accordance with CMS 8 & | C letter INNS (Please see attached letter and photo), | | i i 1 j | i [On MN HIN 2014 between 8:30am, | 1 OR I Piva irre Oe Fatty 6 00er ‘Weontncaion shoot Page 82134WMS). 2014 b:03PM — EFFCU PINES HIATUS DEPARTMENT OF HEALTH AND HUMAN SERVICES fe4ot] 7 PRINTED: Sanna FORM APPROVED HOLLYWOOD HILLS REHABILITATION GENTER, LLC MEDICAID SERVI STATEWENT OF eRCeNCiEs |x) pROWDEMSVPRLERCUA ND BUS Or SOMREETION BENTPGATION NUMBER. 405024 Byun iE OF PRORDER DR SPREE “SiREET ADORESS, CI. SITE EP CODE 12000 95TH AVE HOLLYWOOD, FL 33021 ra NN reo ears Coe er CEH Tae | __Sowakv sramrenT Orpenpances >| __pROVOERES FuaiOF conREcTON @, fee Monnaie — | vbw | eicitomemencrenaanoee | caprov Twa | REGULATONVORLeCIEMTeymGwouATON) | TTAG’ | CROBEAETERENGED TO HEAPPROPATE, i ‘DEFENGY) i | | 082 | Continued From page 8 | 62] i | and 4 pm. accompanied by the Meintenance ' | rector during the observation tour was noted 1 | that in.36 out of 29 mame onthe fst for and | { | 21 out of 30 amet onthe second floor, there is | automate fre sprnkier protection in the ' [resident MINE An interview was | | oonducted at his time with the Maintenance : | Data who acknowledged that he fre spreler ' [heeds were rtinetaled s per manvfacure and ! code requirements, | | caniws vrtat y itr | | The findings were acknowiedged by the | | Ramsar fa vered by be Maiterance | « Director a the time of observation and at the exit | } | conference on NINN 20% | i | Actual NFPA Standards: NFPALSC 104 (2000) 19-1. NFPA 1 (2000) 7-1 | 1 nd NFPA 13 (1998) 6.5 installation offre} j | peier systems. 1 \ 076! NFPA{O1 LIFE SAFETY CODE STANDARD —}-_K076|K-076- NFPA 101: Life Safety Standard- S8=F/ } medical gases. | Medica! mga storage and admiration areus are | | | protected in accordance with NFPA 88, Standards Plestc covers found covering the E size j | for Health Care Facilities. |mumuae cylinder in the mangeg cart wore | L removed. i sized mmm cylinders found to be loose} and freestanding wate all taken out from the maintenance shop and stored = (B} Locations for supply systems of greater than socured in the mamma Storage amin thet 3.000048. ae vented te the outside, NFPAGS {est and second foo. There will never be | 43142, 19324 {more than 3,000 cv. Ft. of maga storage in these mamma because en E cylinder only hoids 26 cu. of mmm ond the faity” | wil never store more than 120 E tanks in | {any storage RIB one time, | Fai so tesnnon saa Papa batt— MMS, 2014 1:03PM EFFCU PINES HIATUS | PRNTEO: FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES GH MATHLE cOKSTRUETION [oc pare suey ‘A, BUILDING 01 = MAIN FED ‘COMPLETED Ls ssya018 Tai OF FRET TR PER ‘REET ADDRESS OMY SINE DP CODE m0 aeTH AVE HOLLYWOOD HILLS REHABILITATION CENTER, LLC HOLLYWOOD, FL 33021 pay ‘SUMMARY STATEMENT OF DEFICIENCIES Salo | PROVIDERS PLAN OF CORRECTION, | cout "Eo Giltewotiitaormmenomncoy | HE" oldesaebenmazo rhe ‘intonare | "bee ; | + —— K 076 Continued From page 9 | K076| SNE rounds wil include jourants} i i observing for any other Mmmm cylinder ' not propery stored and secured, by the ‘This STANDARD isnot met as evidenced by: {| Director of Engineering. ‘Based on observation and staff interview, the | faclity failed te properly etore medical gases. This | Fingings of these rounds will be part of a | deficient practice affects alt smoke | compartments, staf vaitors and al residents. ‘The facity has the capacity for 152 beds and at the time of survey the census Wee 134 ‘The findings include: 1, On I HRB 2014 between 8:20 am. ‘and 4 pm., aocompanied by the Maintenance | Director during the observation tour twas | observed that: in al least 3 areas where crash ‘type car's with an & ized mamma cyiider were found to hava a plastic caver, which completely ‘covered the NN. An iniervicw was conducted zat his ng with he Naintenance Director who ‘acknowledged thatthe Mmmm Wes iepreperly stored, [2 On ENE BUBB 2014 between 8:30 a. j and 4 p.m, accompanied by the Maintenance | Director during he observation tour it was, ‘observed that: in the maintenance shop area at ‘east 11 E sized mmm cylindars were found to ‘be louse and freestanding. An interview wes Conducted et tis ime with the Maintenance . Director who acknowledged that the amgm was | Improperty stored. "The census was verlfed by the Administrator, ‘The findings were acknowledged by the ‘Administrator and verified by the Maintenance | ‘report from the Director of Engineering 10 the QA committee on a monthly basis, and to be monitored for the next three ‘months by the QA committee members. | | | | }- ‘acy oo ‘Feentneaton shee! Page 10 oF 14WB. 2014 1:03PM EFFCU PINES HIATUS | no: DEPARTMENT OF HEALTH AND HUMAN SERVICES: FORMAPPROVED SERVICES CVE NO PURRucAIA | Og) WATE CONSTRUCTION [xn care survey ox rowers {IDENTIFICATION NUMBER: A BUILOING Of - MAIN I SourereD s0s02t yin. soaone "WAME OF PROVIDER OF SUPPLIER “STREET ADDRESS, CITY, STATE, 21° CODE 1200 astH aE HOLLYWOOD HILLS REHABILITATION CENTER, LLC HOLLYWOOD, FL 33021 Tan) amiizaereue at cians | ROvouRE RAN SFCOrRESTN To (eacivencencr MUsy pe ecepes ar FUL, prem | (exc connecr 0 Por | NESUUORY on SCIOENTYNG MF ORWAION EX feagattemcas tone armonare | MMEE™ K 076’ Continued From page 10 * Actual NFPA Standards: (NFPA $9 (1989) 4-3.5.2.1 (7) requies that an mmm cyincer shall never be draped with any | material such as hospital gowns, mask, or caps. [NFPA 89 (1086) 4.35.22. Storage of cyinders [ond containers. NFPA G@ (1290) “Tequires a precautionary sign. NEPA 99 (1690) {5.1-18.5.2 requires that emply cylinders shal be | segregated from full oyinders. The empty and | full oynders were not segregated, NEPA 99 |{1900) 4-2.5.2.1 requites gases in Cylinders and | Liquefied Gases in Containers - (b) (26) Cylinders | shal be attached to a oyinder stand, (27) | Freestanding cylinders shail be property chained | or supported ina proper cyinder stand or cart. K 406 | NFPA 101 LIFE SAFETY CODE STANDARD z 3 I IL K 1081K-406- NFPA 101- Life Safety standard. 0141/2088} $50F| cemorgeney generator. | Hospitals, and nursing homes anc SRN wth He support equipment, have a Type | Essential { Electrical System powered by a generator with a the panel working on the remote transfer switch and separate power supply. The {generator arm, | BES is in accordance with NFPA 99, 3.4.22, | 3a244, [Tre company wi come outta hook it up Ho the portable generator | ! An outside company was called in to get | i i | I L i | This STANDARD Is not metas evidenced by | Based on observation and staff Interview, the “footy fled fo maltan the emergency generator | to manufacture and code requirements. This |‘ deficient practice affects sli smoke: compartments, staff, visitors and all residents, | | | The facility has the capacity for 152 beds and at ' Realtones | Lt i i aa an aaa a ere erMMS), 20i4 1:04PM EFFCU PINES RIATUS Ko. 4811? ia PRN: VT DEPARTMENT OF HEALTH AND HUMAN SERVICES: FORM APPROVED ERVICES M8 NO SMonimtoceomccron” | Gosreeincwtanner | Gyusqe gt AN FED. | cetesaras 99024 4282014 TARE OF PROVOER OF DOPPLER ‘STREET ADDRESS, CTY, STATE, ZP OODE HOLLYWOOD HILLS REHABILITATION CENTER, LLC son asTH Ave HOLLYWOOD, FL aozt a) Samm aoe oe pamoee ——T FOR! eadlbththec muse mecttee ou TO | AEGULATORY OW (6c IDENTIFYING FORMATION | 2 [PROVIDERS FLAN O® CORRECTION = ed (GAGA CORRECTIVE ACTION SHOULD BE FON aS ‘Ross ne DEFICIENCY) — $e AR Po ne Cara K 106; Continued From page 11 ‘Tho findings include: | Cn SENN AEMNM 2614 between 8:30 2m, and 4 pum. accompanied by the Maintenance | Director during the observation tour & was noted # thet: when tested, the remote generator alarm ‘Hocated near the nurses" station failed to function. An interview wee conducted at this time | wan the Maintenance Director who act | that the remote alarm was not functional. IFnot | | malniied the emergency gerne maya | | witout stat being aware ofthe generator! | MEMIBEEEIL No acditonsl writen documentation | | to substantiate compliance was tecelved at the | | ext conference, [ The conus was vertied by the Administrator. ‘The Bngings were acknowledged by the Administrator and vertod by the Maintenance Director at the tme of observation and atthe exit conference cn LT 2014. ‘Actual NEPA Standards: | NEPALSO 104 (2000) 486. System design ané Installation. NEFA 99 (1998) 2-4.1.1 and NEPA 10 (1880) 8.6.62 requie ang NFPA 80 (2000) {3-41.16 Alan Anunciation, Code requires @ | Femole annunclator, storage battery powered, | shall be provided to operate outside of the | genrating MINN 2 location readily observed by | operating personnel eta regular work station K211 | NFPA 101 LIFE SAFETY CODE STANDARD | ss! | Where NINN Based IIB Rub (ABH) | cispencers are installed ina cortidor: oThe corridoris atieast 6 MIM wide |e The maximum individuat clspener i ‘evowin 28024 K 106) K211]k.211.NFPA 101- Maamel-besed| Pact 0015 acemas, (“ot | | | i | | oe iispenser (The NNNL-based IN-rub dispensers [observed to be instaied directly over or lacjacent to the electrical switchos wore all inemoved. (Continued) Teontnualon sheet Page 12 of 14MBG, 2014 1:04PM EFFCU PINES HIATUS No 411. A DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED THF PRGVDER OR SUPPLE TTREET ADDREDS. EY. SATE P CODE ‘tea NST HOLLYWOOD HILLS REHABILITATION CENTER, LLC WOLLYWOOD, FL 3302 aa eae, "FROVERS FLA OF OORREOTION oS POS; ASMA Buetnepnecooepaveua | prance | GAGHCORRECTMRAGTIN SOUR | COBEN TES | feduurononistoccrevnc romani, — | "Tag! | CHORDRETERENEED THE APPROPRAYE, | : i f K 211 Continued From page 12 | K211 ay omer aspensers found drecty or peat sabe 1.2 iter (2 Rers in suite of “Solace NIN sources vat akon i ‘out and installed away from any [Mfetspensers hae a minimum spcg of | source. | fom exch other t | | | Jo Not more than 10 gallons are used in a single | ‘The Director of Engineering will eonduct [smoke compartment outside @ storage cabinet. rounds to ensure compliance. | etigenge's ae nti oer or aja | | | ‘an MARNE source, |citme toes carte, ‘the building is ful i = 0327 Cr a 22241, 437 { \ i "This STANDARD Isnot metas avdenced by | | Based on observation ard wa infeviow, tho city ‘esto poser) mtalidapenses | [folowing the requtererts fr MMMM Dased | | ML cispaneat installation. Dispensers lore rann | i and ocoupants.. The fait has the capac for "482 beds and ot be time of urvey the oensus | was 126 | 1 |The findings include: end 4 p.m, aocomy | | Director during the observation tour twas nated | | that trougnout the facity, in resident mmm | _MRMMMRL-based IML-ub dispensers were i “stale droaty ove or adjacent to eel i IMBMIE sources, The Maintenance Director nowledged the facility had installed | MEME basec MBB dispensers drecty over ‘or adjacent to etectica MMNEME sources. i | | | eo err rey Enero aoe aco: 008H ‘eoninsaion sneak Page 13416M3). 20/4 MMMM EFFCU PINES HIATUS No4att 7 PRINTED: ‘2/so/2014 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDIGARE & MEDIGAID SERVICRS_ ONE NO. srrexewt oF pencenerss |) aowoensurruecun | oi mATWLE ConsTRUCTON vs ove save ino piivorconneene GEMPEmposiames |G cae of MAN FED sours sop0et 2 vas. sasy2044 WEF FRO ROTA ‘FREETAODPESS ESTATE EP CODE ‘me0n 28TH AE HOLLYWOOD HILLS REHABILITATION CENTER, LLC HOLLYWOOD, FL 39028 BRR asi ne enor inet be maeceorD oy TL Sx | qacctancineAcionsioibae | cowie The" MeGuATonontsetoacTemme nronaron | "ag! | @nGSEMErEARNERDToyEoveROMnITE | ER i i ercmNcy) i be — | 211 | coninaed From page 19 i Kan i | The census wes verted by the Administrator, | } 1 The findings were acknowbdged bythe i | administrator ana verted by the Maintenance {rector at the time of observation and tthe ext | 1 {conference I 2014, | | pctual HEPA Standards i | LNEPALSC 101 (2000) 18.32.7, CFR ML | | a a i | MIMMIERL Dispensers shall oct be istalled over | |oreety acento 7 MN eouze i | It : | i i ; i | | ; | : i | i i | : i | | i | t i : | | i | ih ; i | ! i | | t i | | i i It | | | | | i i i ! i i i j | i } | ' | i I i s. a So Ni ere Coe ver s8024 Facy 008 Teontouaton sheet Pape 14 oFMSs 2014 1 4PM ARC Fe | Uisensure deficiencies found atthe time of the Mee | 5 An unannounced annual fire and Life Safety State Licensure survey was conducted to determine compliance wth NFPA Life Salety Code (LSC) 401 (2009} Chapter 2; all NFPA mandatory i ‘requicoments adopted per NEPA ‘01, and! applicable Florida State Fire Marshal's Rules and | Regulations, 68 A-SI 60 A-63, FS 633.022, and State of iorda Building Code. | Facility as surveyed wes bul or icensed in 1054 {witha bulising changes in 1972 anc 1989. ‘Buiding may be of Type i (111) construction. two | story, 52 ded nursing home and has (10) smoke | compartments, Building features and protection "include 2 complete supervised fre alarm system, a complete automatic fire sprinkier sysiem anda temporary generator, The buling is | connected to a Hospital and shares all We safely features including fre alan, sprinkier ‘and generator systems, The facity administrator indigated there are no Fire Safety Evaluation ‘System (FSES) or waivers, Administration indicated that no corstructon or modifications ‘were made to the buling since lest years survey| ‘which would change the orginal approved building blueprint plans, On the date of survey the facity was notable fo provide bue prints of} EFFCU PINES KIATUS Ne 4st). AD PRINTED: FORM APPROVED (OMDERSURPLERTUN | KO MULTIPLE CONSTRUCTION [aa ome Rey ARO PUANOF CORRECTION ENTPCATON MOMBER | A eumoee: 2 -MAINLIC Sou vere 09614 suum, saaniaot4 ‘ae OF PROMIDEN OR SUPPLIER STREET ADORESS, Gy, SYATE,2P CODE 1200 N 35TH AVE HOLLYWOOD HILLS REHABILITATION CENTE) — Hovtywooo, FL 39021 ‘ajo | __ Salam sree OF ERNE Tm] __PROVBeRe mLan GF CORREE TON we, ‘DERENGY HUST DE PRECEDED CORRECTIVE ACTION SHOULD colttene MEX ERNE ataotienesieonco, |g” | oldsskaretaepyoeAmoreate | “OVE aiency i 000. Intl Comments j Keo i 4 | | State Licensure | | £3 Building: 0104 £6 Plan Approval: 1994/1979/1878 | KT Survey Under: 2009 Existing | 8 SNFINF | ARelicensure survey was conducted on 1 SUNBE 204. | Holywood Mis Renebiitaton Center had Monstelee31 2014 1:05PM EFFCU PANES HIATUS fo 4aT) PA re FORM APPROVED. SIATEMENT OFFICERS — |) PROVOEARURPLIENELR | Gt) MATALE CONSTRUCTION feayome mame Rieruater esanecrion ommeaTowMnoer — | § siqone:oz-MAN UC coueLETED oust 5 wns sansrg0t4 ‘at OF PREMBER OR SUPPLER STREET ADDRESS, i, STATE, 2 CODE 2200 N SSTHAVE HOLLYWOOD HILLS REHABILTATION CENTE! ot ¥woo0, FL 33021 | 208 ‘DANY STENT OF SERETBICES To, | einen arcoeeston ROE eacenencinoy ust os pneceneoayrat =| neroe | oamacrve eran srauee | oofere Tae, , MOLAR ORLoGIBEMTeNG HORT "TA otorsnmemngensgearmoranic | "Ore ‘K000! Continued From page 1 Ko00 i ‘the faotity construction, Special features of this i «fait inefade sharing the bulging with | MRBRREEN Hospi an having ateporay | emergency generator for a number | peucrg te yarseuney Ree ‘count check was done, | Se TE a | with NEPA LSC ( ng deficiencies were cted as K tags a6 result of | these areas of non-compliance: i 1013: NFPA 101- LSC 2009 Construction Type KO13 | K-O1aNFPA 101-486 2009 Construction zz SS*F (Exiting) Type | ‘The eructure meets he Stunden or EXISTING | 4, Fire stopping materia's (3h) wil be | ‘construction for fype and height, i bulk before: reapplied in incl accordance wih the | NNN NFPA 101 Life Safety Code (2008) appropriate tasted UL penetration deta to | 18164 all areas where improper fire stop penetrations were observed, The UL L {ested deta used for exch penetration will i also be avalable for review to inspect how t he 2M product has been usad in stick tn cs Rue wenotmet a8 we | feccordance with the UL tested deta is Statute evidenced by: (Photos are ateched | Bute on cbse, win oeuret ew, Probe ae | view, the facility ales to maintain jrocior of designee | Solange wal spares Ts defen | Pe ee mee practice affects all smoke compartments, staf, { a Fee er rae oo tacmynacine | ses al smoke bere fr iar capacity fr 152 beds and atthe time of survey | the census wes 124, '3. A preventive maintenance schedule wil i be implemented to ensure that all cfing The findings mouse: i ‘and wal penetrations are sealed with fe $ On ANION NN 2014 between 830.2, | ried cauking,semi-snnualy. 2 ind 4 pim., accompanied by he Maintenance | * Director during the observation tour twas noted | thatthe wore improper adr unseated | rn — ‘STATE FORE wane Wearieuatos abet 217" fre-stop penetrations observed. Examples Maintenance Director or his designee to | ‘the Qualiy Assurance committee on its! WS! 2014 MMMM EFF PINES ATATES No 46t1 7. PvE FORM APPROVED BMT coNETRUETON [ooaTE SREY A. BULDNG: 02 MA LIC ‘SoNPLETED Bis, s2ntaote {WHE OF PROVOER OR SUPPLIER STREET ADDRESS, it, STATE, CODE 1200 N STH AVE HOLLYWOOD HILLS REHABILITATION CENTE! ori ywoon, FL S80e (ae Soman araTeWeNT oF DeTGES | pROWpEREPLN/OE comRECTON | SRiri| ACHDEMCINCY MUST Be PRECEDED BY TULL | ener | GACH CORRECTIVE ACTION SHOULD BE a TH [REGULATORY OR LSCIDENTIFYING INFORMATION; “tag” | CROSEREFERENCED TO THEAPPROPRITE |” OTE 2 \ i ‘beret 1 048! Continued From page 2 Tots |a.Ai ndings wil be repered by he amma i i include but are not imited to the folowing: £ (1) nat east 2.8 areas whare ping through the Me wat, fre-stop material ecourred the fre | walls above fre coors in fre compartment division wats, (2) In @ least 4 areas where pining through the ‘i wal, fre-stop material occurred in the air handler NOONE fre wal, ! 9) In atleast 2 areas where piping through the: re well, fre-stop material courted in the fre wall ‘above the communications mmm (4) at east 8 areas where piping through the fire wal, fre-stop material occurred in the flammable tiquid storage RIE wal, (8) i at least 3 areas where piping through the | fie wa, frevstop material occurred in the main | clectrice NIE wal Inaproper fire stopping voids ¢ fre barrier rating and is considered a zero hour rating. An ‘nerview with the maintenance director at the “time of obsetvation(s) reveaiad he could not produce any bype of documentation showing the “Te stopping was incaed per the manutectures. specfications forthe fre wal No documentation of meeting manufacture { specifications, UL.or national recognized "products to seal the hole penetrations to the | equired fire barter ratings were provided. No + additonal writen documentation fo support the + fig rated protection by of he frenstop penetrations was provided at the time of > ext ‘monthly meeting and willbe montored by the QA committee forthe next three | months, and serivannualy thereafter. 5, The Administrator / designee wit conduct quarterly and eemivannusl, i | i | | ' | | i | | a aa ‘STATE FORM “ scat Weosrustin sat 94731 1014 1:05PM EFFCU PINES HIATUS fio. 4811 RE ‘FORM APPROVED ino Nee Ee ey POVGEVSIPTIENIR | SMILE SOaTRUSTION aaene RRR See aeoomecron eee | ee wane Set Le = ene | TE OF PROVDER OR BUPFUER STREET ORES YATE CODE 1260 36TH AVE WoULYWOOD HRLS REMABLITATION cENTE: — I200NSETHAVE cab) RT SEE oF GOERS 3 | ET, | PREF | DBAICIENCY MUST BE PRECEDED BY FULL Paar | {BACH CORRECTIVE ACTION SHOULD BE COMPLETE. NN eA | "Mc | clfusnaranexcagrorearmore |; OR | See O19. Continued From page 3 ! Kors. The census was verified by the Administrator, } “The findings were acknowledged by the | | Administer and was verified by tne | Maintenance Director al the me ol cbservation andthe eit conferees on | 2014, Cass tt + Actual NFPA Standards: i | i | i i NFPA 101 LSC (2000) 4.4.8 System I design/netalltion. Any fire protection system, i ‘ouiding service equipment, feature of protection, i vor ‘provided {o achieve the goals of tals i ‘code shal be designed, nstaled and approved it { ‘accordance with applicable codes and tandards ' _ referenced in chapter 2. Chapter 2.1 general. The | } docurnents or portions thereo sted in this i "chapter are referenced wii this code and shall i > be considered part ofthe requirements of is | document Incuded is ASTM E 814, Standard tent method for fre tests of through penetrations | "fre stops, 2002, NEPA LSC 104 (2009) 422, i 1 whioh requires structural integrity is maintained, "and 4.8.20, whieh refers to conestions fo * aceupancy, 18.1.8, which covers the minimum i facity construction requirements. NFPA t (2008) I 1 12.3.2. required fie-resistive conetrction, | lmchuding fie barriers, fre waits, exterior walls due! | {o focation on property, daft stops paris, and {eof coverings, shall be maintained ang shal be | | properly repaires, restored, or replaced where i ' , atored i i i | moroperyinstale. i i i O18 NEPA f0t-L8C 2000 tenor Finan MMR | KO15 | K-O15- NEPA 101 Lite Safely Stender! - | seef! flame spread cating of interior finishes | The intetior fish tor moma and spaces, not used! ‘(Continved) oh STATE FORM, od aescat eanpuaion cnet aca?MRS). 2014 MMMM EFFCU PINES HIATUS No 4811, 8c mm ‘FORM APPROVED : TRO ee pee | Rare PRES 400814 BvaNG Aaissi20t4. recent Trani ov sre oie tm uae HOLLYWOOD HILLS REHABILITATION CENTE? HOLLYWOOD, FL. 33024 2S Bees, 2 LSeeee a. Si. A RGeaSGrERMeoas «TE Te, | Ey K.016: Continued From page 4 for eowidors and exit ways, shall have aflame spread rating as required including exposed Interior surfaces of bulkings, such as, fixed or ‘movable partons, columns, and ceifngs, NEPA, 1101 (ile Safety Code) (2008) 18.3.3, 193.3, ‘This Statute of Rule is not met 2s evidenced by: {Based on observation and staff interview, the facity tailed to maintain the fame spread ratings | for various interior finishes inthe faclty. This deficient practice affects ell smoke comperments sta, visitors and al resents. ‘The facity hes the capacity for 162 beds and at ‘the te of survey the census was 134 "The findings include: On RNIN HII 2014 between 8:20 am. and 4 p.m, accompanied by the Maintenance Director ung ie obsrvaton tu 8 was need ; thatthe focity has un-rated plastic foing panel ‘ype doors on the resivert RIANA The 1 Sogets were noted in approximately 36 out of 39 rooms on the frst foot and 2 out of 30 mame + on the second floor. When requested, written | documentation ofthe fare spread ratings were | not produced by the faclity, The use of un-ated "Interior hs that do not ree te required fame spread ratings could generete excessive WAM sTr0K8, quickly spread fre, ond endanger | occupants in the event af a fre. An interview was ‘conducted at this tne with the Maintenance Citeotoe who acknowiedges thatthe feciliy could ‘not produce documentation of the fame spread rating. ‘The census was verified by the Administrator i first floor and 24 out of 30 | socond fioor, willbe removed and a self | “contained wardrobe wil be installed isi) the niche, ‘STATE FORM aca Arentpution et 217WM). 2084 1:06PM EFFCU PINES HIATUS No. 4811 ._ PRINTED: FORM APPROVED, | maximum individual qispenser lll capacity shalt "bes gal (1.2 L) for dispensers in mm + Soridor, and areas mm tO coriors; A gal (2.0 LYfor dispensers in sutes of mmm The 'spengers shal have @ minimum Rarzortal {Spacing of 4 from each otter Not mote then ‘an eggregate 10 gal of UNNI-besed MBNE-Tib = solution shall be in use ina single smoke * campertment outside of a storage cabinet, ‘Storage of quantities greater than 6 gal in @ single 1 Smoke compertment shail maet the requirements | of NFPA 30, Flammable and Combustible Lguids ‘Code; The dispensers shall not be installed within ‘Tineh (5mm) above, to the side, or beneath, an {BIBIEB source. In locations wah carpeted foor ‘coverings, dispensers instated directy over ‘carpeted surfaces shal be permited niyo sprinkered smoke compartments. NEPA 101 Le Safety Code (2009) 10.8.2.6 &19.3 ‘STATE FORM. STATGHENT OF rICENCIES | pc) PROVOERRUPPLILR | Taj tOLE CNTRDETION SNS Pent oF CORRECTION EMIPOATON MOE | & nunpnec on MAN Lie 100811 Swe, sainona "WARE OF PACHTER OR BUPCLER ‘STREET ADDRESS, CY, STATE, 2P CODE $200 N38YH AVE HOLLYWOOD HILLS REHABILITATION GENTE! Hou 'wwociy FL a3oat or ‘Simian SeaTEICNT OF DEFENCE © ‘POWDERS Fa oF SonaecTON iio (SAGHOEMOINOYHLGTEEPRECGIEDEYFULL | PREER || GRE GDRRECTIE ACTION SHCA OG He REOIMATORY OR LC DENTE HFORMATON) Tas" | GROSEREFERERGED K O18, Continued From page § Kos ‘The findings were acknowedged by the | j -Adminigwator and veried by the Maintenance { Director atthe time of observations and atthe ex ‘conference or TT 2014, | class th | i ‘Actual NEPA Standards | | NEPALSC 105 (2008) 0:2..4 021.3..4, which res compliance with the requirements of 102 interior Finish, KO1® NEPA 101-LSC 2008 MINN Based MMMM Rub | KO16 —|K-O16-NFPA 101. BNBUMMI-Dased BME _ SerF {dispenser instalation. WRB basec NNMB-Tub dispensers shall be i protected in aocordance with 8.7.3, unless a of |The Mmmma.vesec MEMR-rub dispensers | the following condiions are met: Where lobserved tobe installed direct over or | | dispensers are installed in como, the corsdor djacent to the electrical switches were at | ‘hall have a minienum width of 6; The removed. SR i $$$ A $a wm aenzt other dispensers found directly ot sources wil be taken lout and ‘awey fom any |source. [The Director of Engineering wit conduct rounds to ensure compliance. eons net 7WMS). 2016 1:06PM EFFCU PINES HIATUS No 48tt?, : PRINTED: FORM APPROVED istration STATEMENT Or ERCIENCIES | (AN FROVDERAUPPLERGLA | pa WAATPLE CONSTRUCTION (oar oare suey AND PLAN CF CORRECTION ENTPICATOU MBER — | pun: 02 - MAING ‘COMPLETED NAME OF PROVIDER OR SUPPLIER [STREETADDRESS, CITY, STATE. 2 CODE: +1200 N STH AVE WOLLYWOOD HILLS REHABILITATION CENT: HOD NACA ot Baie “SOARARY STATEMENT OF DEFCIENOES Tie | PROVEN Puy OF conREETON Tan Prgrix | (SACHOEPICINGY MUST EE PRECEDED BY FULL prerx | _(EACNCORRECTIACTION SNOND BS | COMPETE aa” REGULATORY OR LSC DENTVAG FORMATION THe | GROSEREFERENCED TO THEAPPROPRIATE | “DATE i | | | This Statute or Rule isnot metas evidenced by: | Based on observation and staff Interview, the ‘ eciity alles to propery instal. } { folowing the requirements for ad j | IMMB-rub dispenser instalation. Dispensors | | incomectly installed may endanger staff, visitors | and occupants.. The facility has the capacity for * 452 beds ang at the time of survey the census. 5 was 134, _Thefngs ince: 1 | On IIE BRE 2014 between 8:30 a.m, | and 4 p.m, accompanied by the Maintenance | Director during the observation tour it was noted | that: throughout the fatty, in resident am Pore cee ec Seat ‘installed directly over oF to: WRRBEML sources. The Maintenance Director ‘acknowledged the facility had instated EB-bascd MNIR-rub dispensers directly over or adjacent to electrical MINN sources, | The census was verified by the Administrator. | The findings were acknowledged by the + Administrator and verified by the Maintenance Director at the time of observation and at the exit conference on IIUUUNNIE 2044. "Clase ‘Actual NEPA Standards: ; NFPALSC 101 (2009) 19,3:26, and 8.7.3 which | deternines instalation requirements. i aa —t ‘STATE FORO om weer Vesreaonsnet 70197Wim 31, 2014 1967 EFFCU PINES HLATUS | PRINTED; SA FORIKAPPROVED Agency for Health Care Administration SINENENT OFDEPCIEISEY |p erovBGRSDRUBNELA | GH MARTALE COWSAUTEN BREST Samaroo Ore ence pay 400641 B.WING, AQM2014 ‘wu OFPROWOER OR BUPPLER reer AmEss cr, STATE, CODE 1200 NaSTHAVE HOLLYWOOD HILLS REHABLTAMONCENTE: TRONSETHAVE mae “Fauiiaky gtArEuent GF CERCIOES Tp” 1 pRovibeta ua or commeeniON | a Hime gacnercmormstoe preceseoovrun © anarx | AGHCORRECTWE ACTON oLUDE | colmere To MEkieWeracomrimcwonuroy | “hg | oiEREREe oreverermre | SY 616: Continued From page 7 Kore koe NFPA 101-LSC 2009 Corridor Doors KO18 [KO18- NFPA 101-LSC 2009-Coridor | Corridor doors shal be 4 374 inch sold bonded | wood core doors or they shall have a 20 minute } fice resistive rating (Existing ony). Ifthe building | or smoke compartment is fuly sprinkiered, the ! door shal only resist the passage of smoke. ‘Thate shall be no impediment tothe closing of ‘te door, and latching devices shal be provided ‘which keep the door ight slosed inthe frame, Doors: | i i } |All the doors observed not to tatch | ‘automatioally and not functioning propery | nad te tocks replaces. { The otter doors, including the iaundry (MEBMNBENEE were assessod and were repaired by on outside company (Big Lock For NEW doors, roller latches are prahibited NFPA 104 Life Safety Code (2009), 18.3638 | 19363, 1 jana Key), (Please see attached invoice) [the Director of Engineering (Maintenance) |wil regularly assess 28 part of 8 lpreventive maintenance sehecule, ail fre ldoors during fire dis. Phatos are lettached, ‘This Statute or Rule is not met as evidenced by: | Based on observation and staf interview, the aolity filed to maintain the bulging door opening] { assembles. This deficient practice affects al! | smoke compartments, staf, vistors and el | tesidents, The facility has the capacty for 162 | beds and at the tne of survey he census Was i134 i ‘The Administrator / designee wil spot | | 2 The findings ince | i i i | ' check aif doors on a montity besis, then quarterly thereafter, to ensure compliance. | On IRIN mame 201 etween 8:20 am, | and-4 pim. accompanied by the Maintenance | Director during the observation tour was noted | that when tested, vartous eordor doors od not { close and latch inthe door frame. Doors did not {meet the code requirement of providing a means | ullable to keep the door closed. The door did | notlateh closed inthe door frame andlor the door | 0 the doar fame has an opening which wl alow | te sorend af smoke through tha door. Some ‘examples inciude but arent Emited to: 25021 Mearivaten sat bof 17Mmm 6, 2015 1:49PM EFFCU PINES HIATUS Ko, 4988 P. 9 Re FORM APPROVED PROVDERGUPFLERGLA | DU/MITTPLE COMETRUCTION [och pare sume DeNTsIeATION MMBC | SuacwiG: 2 MAIN LIC COMPLETED sw s2rtsrant4 NAMEOF PROVIDE OR SUPPUER ‘STREET ADRESS, CTY, SATE 2 CODE 4200N 35TH AVE [_HOLLYNOOD HILLS RERABILTATION CENTE! oLL¥a7OOD, FL 024 rd ‘GoMMAY sTATeue OF DEFCTBIOIES | PROVIDERS PLAN GF CORRcrION Tos) Fa2eh each DRRCIENGY MUST RE PRECEDED BY ML, PREF | _(EADNGDRRECINEAGTIONSHOWUD Be | omeueTe ‘TAS REGULATORY Om LSC DENTIPYING INFORMATION) Tua, | cnOBSREFEREycaD IO WEAPPnOPRTE | “DEE K 018! Continued From page 8 Kor (3) Kitchen to corridor doce. 1 (4) Fist oor smoke compartment doors times 3. | An interview wes conducted at these times wth | he Maintenance Director who acknowledged and | witnessed tha! the contidor doors id not meet th, code requirement of providing & means sutable p keop the door ciosed. No adoltonal writen + decumentation to support the testing of te doors ‘or function or providing @ smoke barrier was | provided af the time of exit { The census was vediied bythe Administrator. 1 The findings were acknowledged by the | Adminiatrator and veritied by the Maintenance | » Ditector at the time of observation and at the exit | conference oF A 204 i Crass ‘Actual NFPA Standards: NFPA LSC 101 (2008) 19.38.3.9, 19:48. + instalation and maintenance of assemblies and dovios used to protact openings in wats, floors, + and celings egainst the spread offre and amoke ‘thin, into, or cut of buicings. NFPA 80, corridor | doors to be provided with @ means sutable for ‘keeping the door dosed. K 062 NFPA 101- LSC 2008 Sprinkler koe | K-062-NFPA 101 Life Safety Standard ‘SS=F inspecton-Testing ‘utomatic fire sprinkler system _ Al automatic sprinter and standpipe systems The closet doors, including the shalt and | required by this Code shal be inspected, tested, the rod, wit be removed. (Continued) "and maintained in accordance with NFPA 25 + (2008 edition Standard for the inspection, + Testing, and Maintenance of Water-Based Fie Protection Systems). NFPA 101 Life Safety Code KER Fin OOOOT STATE FORM, “ peqoas eonbuason set 57fam 6, 2015 1:49PM EFFCU PINES HIATUS He 6988 4 PRAT FORM APPROVED inatrabon SUATEIENT Gr OErGiENGES |i) PROVDENBUPRGEREEA | 02) TALE COMTTROCTION Rae TUNE So mavor comecnon COREE aaa ure 00614 8. Wiha. AziNI2044 Nak OF ROVER OR SUPPLE REET ORES, CY, STATE CODE ‘200 n3STH AVE HOLLYWOOD HILLS REMABIITATION CENTE, — JAUNASTINE | Goa Siimenormcate Ta | _pioaens ru orcommeeron Tow Fag | SEPCRIGTST SE PRESCDED av ruL | PRERX iononpee | colaire bs Simtowonisoecmirmenromasoy — | "hg | choseAefenances fotmeapongenare OME i i TERE } 7 * ‘062: Continued From page 9 062 jA self-contained wardrobe will be installed 02/11/2015} * (2009) 18.3.5, 19.3.5 88.75, 2 This Statute or Rule is not met as evidenced by: Based on observation, and staf interview, the faciity aled to maintain the builging aulomatic fire sprinkler system to code requrements, This, deficient practice affocs all emoke compartments, staff, visitors and allresidents. | ‘The facility has the capacty for 182 beds end at ‘the tme of survey the census was 134, ‘The findings inotude: On OSU HI 2014 bebwosn 8:20 a.m, | and 4 p.m, accompanied by the Maintenance Director during the observation tour twas noted that. in 38 out of 38 mma onthe fret foor and 1H ost 0 mam on secon far these ‘no automatic the protection athe -eccan O on s ‘conducted at hie time wih the Maintenance £ Diteetor who ecknowiedged Dat the fre sprnkie: { “ heads were not instalied, as per manufacture and | ‘code requirements. ‘The census was verffed by the Administrator, ‘The finsings were ackriowedged by the Adininstrator and verited by the Maintenance "Director atthe time of observation and al the exit ‘ conference on SAREE 2014, lass | Aotual NFPA Standards: NFPALSG 101 (2008) 19.38, nd 9-7. NEPA’ (2008) 7.3.3.9. NEPALSC 101 (2008) 18.1, NFPA 1 (2009) MAMIE NFPA 13 (2007) 6.5 inside the niche. When this work is lcompleted, the warcrobes wil not equira Ispriklering in accordance with CMS & & {otter NINE (Please see ellached letter photo} | | iWe will be working withthe Office of Plans land Construction to request for a desk ireview or a project number to alow us Kime to complete this project ail ‘STATE FORM, Moonta mae 90817MMS, 2015 2:43°M EFFCU PINES HIATUS Mo, 5374 FD PRINTED: SOA FORM APPROVED Agency for Heat Care Administration ‘STATEMENT OF DEFENCES — | 01) PROWBBRVGDOFLENRLA | Ga) WACTALE SONTRUGTON ews [RIO FUAN OF CORREGTON DENTFOATON AER |S puconG-O2-MAIN LIE ‘courtetsD 100611 sw s2rs120t4, AME OF PROVOER OR SUPPUER {STREET ADORESS, CT, STATE 21 CODE 4200 NS6THAVE HOLLYWOOD HILLS REHABILITATION CENTE! YO" avon, FL. 93021 6 ‘Samay SIATaNBN OF DEFENCES Tp | PROWDERS Pan oF CORRECTION “oa Pale : aco ouncevn mist BE PRECEDED BY FUL prtex | @xciconnecTweaction soup ee — | olpuere Tae + AEGUATORVCRLECIDENTRYNG FORMATION — "Tag | CROBBAREFERENCEDTOTHEAPROARATE | ONE | ‘ERC I —~ ‘082! Continued From page £0 082 | ‘installation of ire sprinkler systems, : i K.086; 504.133 FAC, A20.1.4 FOC Addition, Ater& | KOb5 |K-085-S4NNNNE FAC, 420.1.4 FBC 885 | Convert ladattion, Alter, end Convert + When construction is contemplated for new 1. This deficient practice has been | puittings or for addons, conversions, I lscdrassed with the attached reviaw end renovatons, or aterations to existing buildings, lepproval eter showing project number the plans and specifeations forthe contemplated irom the Office of Plans and Construction | ‘construction shall be prepared by \dated MINN 2015 (see attached). | Florida-registered architects and engineets. Al [Therefore no time waver is needed to | ‘contemplated addltons, conversions, satisfy Ko65 as R was wrten it renovations, o” alterations shall be submitted to i ‘the AHCA Ottice of Plans and Construction for ‘The nursing home wil be working withthe | ! approval or exemption from the pians review |Office of Plans and Constuction to i process, Plans and specifications submited for (design, buld and instale permanent | + review shall be subject to @ plan review fee. lgenerator. i EAC. S9A-MMMIM & Florida building Code 2010 | i - edtion 420.44, | 2, The Mill shed found without the { rope paperwork was removed omits} : leurent location, | ‘This Statute of Rule is not met as evidenced by: 's. An AHCA letter coted | Based on observation, record review and staff '2012, is attached as evidence that the | Interview the facilyfeles to notly the Agency of ‘inataations ofthe ext egress doors have ‘changes to the bulking made from the origin ‘been approved (please eae attached liter | + approved plans. This deficient practice affects ait Irom ARCA dated MM 17, 2012), | smoke compartments, stat, vistors and al { rasidonts. The fecty hae the capacity for 152 | Ragan tebe ture census as | i | | The fngingsinctude: | Cr NN NN 2014 Batveen 8:30am. | and 4 pm, accompanied by the Maintenance | [Sotenars me coer we } i 1 wm ass0at Aeannaton bot Hot 7mm STERN OF DeRCENCES ND PON OF C98 a EFFCU PINES HIATUS No 4811 PRINTED FORM APPROVED o 00) FRODERSURPLIENCLA DENTEFICATION NUABER 00614 Sa, (OB) MTIPLE CONSTRUCTION A BURLOING: 02 - MAIN LIC ‘Dae suave oS Sources samn2004, 085! NAME OF PROMOR OR SUPPLICR ‘HOLLYWOOD HILLS REHABILITATION CENTE! “Ginny Sateen oF oenceNces {(E4C8 DEFICIENCY MUST BE PRGCEDED BY FULL REGULATORY ORLSC DENTIVING FORTIN) © PRERK. oa I STREEY ADORESS, CY, STATE, P CODE 11200 N 35TH AVE HOLLYWOOD, FL 39024 ROME hsb AEPeRERGED 10 ve PPROMMUTE DERGENCY) L Continued From page 11 i | | Examples are noted Delow of changes that were | made trom the onigiel approved plans that | invelve construction changes, where approval { ana permiting was not done through the office of ; BaNS and constuction. On the dates of suvey | the facity was notable to produce any | Socumentato to subsanite that plans were | approved by the Agency for Health Care | Administration (AHCA) office of plans and | Sonetretion (OPC) for work done atthe focity 1 (9) The fality has a temporary 190 KW | generator on a trailer which s he second ‘temporary genertor in a least 3 ar more years | which did not have eny approval tive prints and | no documentation was provided showing this "construction change was approved, reviewed or inspected for code compliance onthe date of ext | No additonal paperwork was provided athe bre of et torn the facility. i | (B) The fcity has a NM shed measuring shout | 40 MMM by 1OMIU vithin 4 BUM ofthe window WANNIME ofthe bulding. ‘This shed is not installed wih huricane steps anno writen documentation was provided when requested showing the Inetalaion wos approved, reviewed ‘or pecmited. No adelional paperwork was rovied atthe time ot ext rom te fac |) To feity tae ates ea king ty arrangements on ext ogress doors. The is requred to obtain approval of revised construction documents or shop drawings which shall be prepared and subrrittes for review and approved to Hustrae corectons or rodfcations " necessiatad by field conditions or ether | provisions to approved plans. During interview wit the Maintenance Director he was unable to produce ary wilten documenteton io — 088 | | | | | | STATE FORM eomovtan hat 120817MMM). 2014 1:07PM EFFCU PINES HIATUS fe 4811 PRE: FORM APPROVED ‘A BULDING: 02 - HAIN LIC 06+ a naa, (Ba) ITE COMSTRUCTON Corea commiereD sayzot4 | NAME OF PROWDR OR SUFPLAER STREET ACOAERS, CTY, STATE, 2P COE 1200 N 38TH AVE HOLLYWOOD HILLS REHABILITATION CENTE, Wotvani Fe sagat (kas | inant rere oT Phe | Ah enGENCY Must be PreeDED AY PL aera | "WG. | REGULATORY OF SEDENTIPNG NORMAN me bo 086! Continued From page 12 Tk oes substantiate the Installations had been approved, ‘or that plans were approved forthe instalation of | | these changes, No additional paperwork wes | provided at the time of exit from the facity. | | | The census was vertfed by the Administrator. ‘The findings were acknowledged by the ‘Aaministrator ard verted by the Maintenance Director at he time of observation and at the exit conference on AAR 11, 2014, Clase Adtuat NEPA Standares; NEPA LSC 101 (2009) 42.1 Occupant Protection, | 457 System designinstalaton. NFPA 1 (2009) | WME permits and HNN NFPALSC 101 (2000) | 42.4 Occupant Protection. 45.7 System ~ dexigrvinstalation. NFPA 1 (2009) ll permits | and 5.7.1. NFPALSC 101 (2008) 4.5.92, (MBO, 7322, 191.1320n 72.183 (1) | NFPA 1 008) 75.1. eques eshte ‘oceted and exit ogres shall be aronged so that | ox are readlly accessibie ata times. NFPA 1 | (2008) RNIN which requtes revised construction documents oF shop drawings shall be prepared | and submitted for review and approved to ;lustrte corrections or modifications | necessitated by eld conditions or ather | provisions to approved plans, NFPALSC 101 | | (2006) 7.9 any devise or alarm intl to rasifict the improper use ofa means of egress _ shall be designed apd insta so that teannct, | even in the case of fale, impede o: prevent + omherpency use of such means of egress, NFPA } LSC 10% (2009) 7.21.52 looks i provided, shat [ iotrequle the use of key. 2100), oF special | knowledge or effort for eperaton from the egress . side ‘PROVDERS pan OF CORREDTION {ACH CORRECTIVE ACTION SHOULD 9 ‘CROSS-REFERENCRD TO THE APPROPRIATE PERGIENCN i colatere one i STATE FORM om 2escas lH eontrann mt 19017MM 3). 2014 1:08PM EFFCU PINES HIATUS He 4811 P 29/32 PRINTED: 12/1a72016 Medical wm storage an administation are | Shall be protected in accordance with NFPA @9 ; (Standard for Health Care Fecities 2005 edition) | NFPA 101 Life Satety Code (2009) 18.324, | 19.3.24 & NFPAB9 (2005), { | This Statute or Rule is not met as evidenced by: | Sates on cbeorvaion ana af rere, the + facil Faied to store mecical gases. This, Sota grace eed a soe | Compartments, staf, vistors and all residents. ‘The fecily has the capaclly for 182 beds and at the time of survey the census was 134. | The findings etude: 1. On MBI 10-11, 2014 between 8:30 8, | and 4 pm, accompanied by the Maintenance | Director during the observation tour twas ‘obverved that i at eat 3 areas where crash ‘ype carts with an E sized IN cylinder were found to have aplastic cover, wnich compote _ Covered {18 lm An interview was conducled | althis time with the Maintenance Director who acknowedged that ine Was improperly stored, | 2.07 MNNNNNN 10-1, 2014 betwaen 8:30 2m, ‘and 4 p.m. accompanied by the Maintenance | ‘Brecor dung tne observation our was | obsared that ine mantenance shop area ot [e001 E sized mm orcas were tune to Be bose and fetetehg. An nrviow wae Conducted at ts ia wh he Martanance | Diecior whe acknowledged hat be Ma Wes , orepery stores . FORM APPROVED ac ae Ata a STRUT aay anppustorcenacenon | compenrcunumecr | 2 MATRLE CONSTRUCTION OS ousceres 00611 s.vaie szunin0sg NAVE OF PROWDER OR SUPPUER STREET ADDRESS, CITY, STATE BPCODE 4200 N 36TH AVE HOLLYWOOD MLE REHABILITATION CEWTE, [UNAETHATE wae Syamaay ser oF DeREEEES o FROG RANGE CORREETOR | — oh t er CeAC inst be oeecEDED BY i | sexeconnectwe seven areas colle "ho! MeGlUtRroniSe DORN aOR | EM | qfeAaleOMe ATEN sheuo ee | “ae i Coreen O78 NFPA T01- LSC 2000 Mea | K076 |KOTG-NFPA401-LSC 2008- Medical ‘otr12015 oF oeses | Paste covers found coverng ne sie | lmmmmm cyinders ih he mm cos were fmeved. Hoose and freestanding were at! taken out [rom the meintenance shep and stored jand secured in the MN storage rooms in the first and second floors. There wit never be more than 3000 cu. Ft. of storage in these rooms because an E levinder only hokds 25 cu, Ft of and the faclity wil never store more than 120 € tanks in any storage room st one ime. (SEEN cours wi include ‘observing for any other mmm cylinder [nat propery stored and secured, by the Director of Engineering, i: i Esicee mann ones four obo | i i Findings ofthese rounds wil be part of 9 report ‘rom the Ditector of Engineering to the QA committee on a monthly basis, and {a be monitored for the next three months by he QA committee members. revcat eoreacon et $61171 0 WE), 2014 1:088M —-EFFCU PINES HIATUS No GB1t P3732 PRIVTED: tareo16 FORM APPROVED. fe Adtinstaton 5 RESIN ae ca PREG 0081 Bevis sarin ‘le oF PROUD On SUPER STREET ones Oy, SATE BP CODE ‘200 35TH Ave HOLLYWOOD HILLS REHABILITATION CENTE] HOLLYWOOD, FL a3021 7 rapa Boro ena 7 ern T So geriensrin tx | gemenes, Ta, TAG | REGUATORY OR LSC IDENTIFYING PIFORMATION) t wf ROSS REFERENCED TO THE APPROPRIATE | ORne Teas 076. Continued From page 14 2 The census was verified by the Administrator, ; The fincings wore acknowiedged by the | Administvater and vetted by the Maimenance | Ditector the time of observations and atthe exit | conference on MINI 11,2014, * Class ut ‘Actual NFPA Standards: | NFPA.LSC 101 (2009) 19,3.2.4, and NEPA 9 2008) 83.13.12 (2) sates an gammy cyinder ‘shall never be craped with any meterias such se hospital gowns, masks, of caps. NFPALSC 10% | | (2006) 19.3.2.4, and NFPA.S (2008) requires ‘medical gases fo be secured, vented and not { soved in closets. NEPA 99 (2005) 83.13.22 if | Stored within the same enclosure, empty ylnders shall be segregated from ful cyinders | Emoty cyindars shail be marked to avoid : and delay if @ ful cyinder is huriad'y, NEPALSC 101 (2008) 19.3.2.4, and | NFPA 98 (2008) 8.3.10.1.2 (3) NEPA.9 (2005) singers dod 5.3.3.3. Cyt dence rains eet | ; be indivduaty secured and iocaled to prevent | | faling or being knockes over. | K 108 NFPA 104-80 2009 Emergency Generator 108 [K-109- NFPA 191- LSC 2009- Emergency | 91/11/2015} SSHF| Maintained generator. Emergency generator maintenance and texting An outside company was calied in to gst | Shall eet the standards in NEFA 101 Life Safety the panel working on the remote generator | Code (2008) 0.1.3. NFPA 110 (2006) 8.3.8, (A aterm, E | fue quality test sina be performed at leaet i | annuslly using tests approved ty ASTM: ‘The company wit come out to hook tup { standaras) / io the portable genayator, ' ROR Fane ET STATE FORM macs odontal 169117MMS), 2014 1:08PM EFFCU PINES Hi inistration No 4Btl P 31/32 PRINTED: tanrera014 FORM APPROVED ‘STATEMENT OF DEFIDIENGIES [cy PROUBENELBRLCRELA | GR AATPLE CONETAUCTION ‘EroCATION RUUER 100611 Sora, ‘A BUILDING 02 - MAIN LIC ay sare SURE ‘coMenere s2ns2004 AME OF PROVIDER OR SUPPLIER HOLLYWOOD HILLS REHABILITATION Cenre; 1200 NSBTH AVE. STREET ADORESS, Ty, STATE. 2 CODE HOLLYWOOD, FL 99024 a Slain Sra EMT OF DERCIeNCeS o MUSTREPRESEDEDEY ra, | sRERK : gon THE); -REGUATORYOR LST DeNTINING MrOmWATION | "Nag! 1 mS ecto Tas AGH GDRRECTVE ACTION swOULD| come | CROBEREFERENGED TO THE APPROPRIATE. | ‘OEFENEN Date ‘108! Continued From page 18 08 This Statute or Rule isnot met as evidenced by: | Based on observation and staff interview, the -fecty fled to maintain the emergency generator | fo manufacture and code requirements, This | deficient practice affects al smoke i | Somporments, sta, vistors and al residents. | The facity has the capacly for 152 beds and at | the Ue of survey the ceneue was 134 | The findings inchude, | On MINNIE 10-11, 2014 between 8:20 a.m. {and 4 p.m,, accompenied by the Maintenance | Director during the observation tour it was noted thal. when tested, the remote generator alarm ‘located near the nurses station failed fo i ‘function, An interview was condticte at this time | wah the Maintenance Director who _ atthe emo alarm wes not funeinal ft | | Maintained, the emergency generator may felt | | wlhout staf being aware ofthe geierator | No addtional writen documentstion | to substantiate complsnce was received af the | ext conference. | The census was verfiag by the Administrator. 1 The findings were acknowledged by the * Administrator and verted by the Maimenance + Director atthe time of observation and atthe exit 5 conference on NIN 5, 2044. Cass ti ‘Actual NFPA Standards: NFPA 99 and NFPA 170 (2005) 5.6.6 require a ‘emote annuncialor, storage battery powered, shall be provided te operate outside ofthe | ‘generating room In location ready observed by | RCAF SOOT STATE FORM 2e902s eosmuatonstaet 180117MMM), 2014 1:08PM EFFCU PINES HIATUS Ne 4811 P, 32/32 PRINTED: soriare0e ‘FORM APPROVED c istration ‘STATEMENT OF DEFIGEWCES — |i) PROVOERSUFPLERIGLA | (RMULTELE CONSTRUCTION [pavBrE sume ‘AO PLAN OF CORRECTION roemmcarion weer. | puuom, 02 MAN LIC covered 00611 Biv s2issigoy "NAME OF PROVIDER OR SUPPLIER SIREETADDRESS, OY, STATE, ZF CODE. {200 NSSTHAVE VOLLYWOOD MILLS REHABILITATION ENTE — ONY Oon ont a6) PROVGERTS FLAN OF CORRECTION om, faba | 3 gopicomemexcronsroubee | comet me 180 ‘CROBS-REFERENCED TO THEAPPROPRATE | DATE it DERCENCY) 409° Continued From page 18 108 | operating personnel ata regular work station. i i i | | | | i | | i i | | ‘STATEFORN, “ ane teonencinn ae 972017SECRETARY RICK SCOTT GOVERNOR ELIZABETH OUDEK NE 19, 2014 Administrator Hollywood Hills Rehabilitation Center, LLC 1200 N 35th Ave Hollywood, FL 33021 RE: Recertification, Relicensure & Life Safety Code Surveys Dear Administrator: On MINE 8, 2014 through IENNNNNE 11, 2014, Recertification, Reficensure and Life Safety Code surveys were conducted in your facility by representatives of this office, The purpose of this visit wes to determine if your facility was in compliance with requirements for nursing homes participating in the Medicare and/or Medicaid programs. Your faciity was found not in substantial compliance with the participation requirements Enclosed are the provider's copies of Form CMS-2567 (Statement of Deficiencies and Plan of Correction} and State (3020) Form. These forms reference the deficiencies that were identified during the visit. You will not receive a copy of this letter and attachments in the mail; you will only receive this faxed report. ‘A Plan of Correction (POG) for the deficiencies must be submitted to this Field Office 10 days after your facility receives the faxed Form CMS-2567. Failure to submit an acceptable POC within ten (10) days after receipt of the faxed statement of deficiencies may result in the imposition of remedies. You will be notified by telephone or fax if your POC is found to be acceptable. If your POC is found to be unacceptable, you will be informed in writing. The correction date indicated by the facility shall be after the date of survey exit. Deficiencies shall be corrected no later than SAMMRRMME 11, 2015. Your POC must contain the following: * What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; © How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; + What measures will be put into place or what systematic changes you will make to ‘ensure that the deficient practice does not recur, and, * How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.¢., whai quality assurance program will be put into place. Doiray Bosch Fie Oice 560 Linton Boulevaré, Suite 500 Facebook com/ACHAPoda Delay Beach, FL S2484 Youtube comiAHCAFiorida Phone-(56') 385-5840; Fax (861) 496-8524 “Twter corvAHCA FL ‘SlideShare nevAMCAF‘oTda ANCA MyFlorida.comHollywood Hills Rehabilitation Center, Lle SE 19.2014 Page 2 Recommended Remedies: Please note that this letter does not constitute formal notice of imposition of alternative sanctions or termination of your provider agreement. Should the Centers for Medicare & Medicaid Services determine that termination or any other sanction Is warranted, we wilt provide you with a separate formal notification of that determination. Remedies will be recommended for imposition by CMS if your facility has failed to achieve substantial compliance by the revisit. Informal dispute resolution for the cited deficiencies will not delay the imposition of the enforcement actions recommended. A change in the seriousness of the noncompliance found may result in a change in the remedy recommended ‘When this occurs, you will be advised of any change in remedy. + Civil Money Penalty, in an amount and duration to be determined by CMS. ‘© Amandatory denial of payment for new admissions will be imposed MINIM 11, 2015 if ‘substantial compliance is not achieved by that time. + Termination of Medicare Agreement. We are recommending to the CMS Regional Office and/or State Medicaid Agency that your provider agreement be terminated on INN 11, 2015 if substantial compliance is not achieved by that time. Hf, upon the subsequent revisit, your facility has not achieved substantial compliance, the CMS Regional Office or State Medicaid Agency will impose the other remedies indicated above, or a revised remedy, if appropriate. informal Dispute Resolution: In accordance with §488.331, you have one opportunity to question cited deficiencies through an informal dispute resolution process. To be given such an opportunity, you are required to send your written request, along with the specific deficiencies being disputed, and an explanation of why you are disputing those deficiencies, to: Attention: IDR Coordinator ‘Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 9-A Tallahassee, Florida 32308 FAX (850) 414-6946 or Phone number: (850) 412-4301 iDRCoordinator@ahca,myflorida,c The IDR request must be sent during the same 10 days you have for submitting a Pian of Correction for the cited deficiencies. An incomplete informal dispute resolution process will not delay the effective date of any enforcement action.Hollywood Hills Rehabilitation Center, Lle emma 19,2014 Page 3 The Quality Assurance Questionnaire has long been employed to obtain your feedback following survey activity. This form has been placed on the Agency's website at bitp://ahca.m com/Publications/Forms shim as a first step in providing a web-based interactive consumer satisfaction survey system. You may access the questionnaire through the jink under Health Facilities and Providers on this page. Your feedback is encouraged and valued, as our goal is to ensure the professionat and consistent application of the survey process. ‘Thank you for the assistance provided to the representatives. If you have questions, please contact this office at (561) 381-5840. Sincerely, pene = is Field Office Manager AMD Enclosure