Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
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)
K0751 Draperies, Curtains, and Loosely Hanging Fabrics
CFR(s): NFPA 101

Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 20.7.5.1 through 20.7.5.3, 21.7.5.1 through 21.7.5.3


This STANDARD is not met as evidenced by:
Based on observation and interview the facility failed to ensure that loosely hanging furnishings met flame propagation criteria as required. Loosely hanging furnishings that do not meet these criteria could cause a fire to spread more quickly and with greater intensity than a loosely hanging furnishing that does meet flame propagation criteria.



Findings include:



On January 31, 2019, between 1030Am and 1215PM, during a walk-through of the facility with the facility's maintenance employee a cloth furnishing was observed to be tacked to the wall in the billing office. The furnishing was approximately 6ft by 4ft and was attached to the wall using push pins. The employee whose work station was positioned adjacent to the loosely hanging furnishing said that she brought the cloth from home. No markings or tags on the cloth were observed that would indicate that the cloth met the appropriate flame propagation criteria.