| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 65C0001001 | (X3) Date Survey Completed 02/08/2019 |
| Name of Provider or Supplier Hafa Adai Specialist Group, Llp | Street Address, City, State Sunflower Villa, 280 Pale San Vitores, Tamuning, GU | |
| 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) |
| K0355 | Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10 This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to store a fire extinguisher as required. Storing a fire extinguisher as required will ensure that it is available, accessible and will function as intended in the event of a fire. Findings include: On February 1, 2019 during a walk-through of the operating room area with the CMS Health Surveyor and the facility's Operating Room Technician it was observed that a fire extinguisher in the operating room was stored directly on the floor near the entrance to the operating room. Both the CMS Health Surveyor and the Operating Room Technician observed the fire extinguisher being stored directly on the floor. |