printed: 10/26/2017 department of health and …the locked exit doors with a combination. a code was...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

CROWN POINT, IN 46307

155733 10/02/2017

COLONIAL NURSING HOME

119 N INDIANA AVE

01

K 0000

Bldg. 01

A Life Safety Code Recertification and

State Licensure Survey were conducted

by the Indiana State Department of

Health in accordance with 42 CFR

483.70(a).

Survey Date: 10/02/17

Facility Number: 000360

Provider Number: 155733

AIM Number: 100290370

At this Life Safety Code survey, Colonial

Nursing Home was found not in

compliance with Requirements for

Participation in Medicare/Medicaid, 42

CFR Subpart 483.70(a), Life Safety from

Fire and the 2012 edition of the National

Fire Protection Association (NFPA) 101,

Life Safety Code (LSC), Chapter 19,

Existing Health Care Occupancies and

410 IAC 16.2.

This facility is a two story fully

sprinklered building determined to be

Type V (111) construction with a lower

level located in the basement with

additions and updates made prior to

March 1, 2003. The facility has a fire

alarm system with hard wired smoke

detection in the corridors, spaces open to

K 0000 This plan of correction is to serve

as Colonial Nursing &

Rehabilitation Center's credible

allegation of compliance.

Submission of this plan of

correction does not constitute an

admission by Colonial Nursing &

Rehabilitation Center or it's

management company that the

allegations contained in the

survey report are a true and

accurate portrayal of the provision

of nursing care and other

services in this facility. Nor does

this submission constitute an

agreement or admission of the

survey allegations.

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: RICB21 Facility ID: 000360

TITLE

If continuation sheet of 37

(X6) DATE




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the corridors, and C hall first floor

resident rooms. All other resident rooms

are equipped with battery powered smoke

detectors. The facility has the capacity

for 55 and had a census of 42 at the time

of this survey.

All areas where the residents have

customary access and areas providing

facility services were sprinklered.

Quality Review by Lex Brashear, Life

Safety Code Specialist on 10/05/17

NFPA 101

Egress Doors

Egress Doors

Doors in a required means of egress shall

not be equipped with a latch or a lock that

requires the use of a tool or key from the

egress side unless using one of the

following special locking arrangements:

CLINICAL NEEDS OR SECURITY THREAT

LOCKING

Where special locking arrangements for the

clinical security needs of the patient are

used, only one locking device shall be

permitted on each door and provisions shall

be made for the rapid removal of occupants

by: remote control of locks; keying of all

locks or keys carried by staff at all times; or

other such reliable means available to the

staff at all times.

18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1,

19.2.2.2.6

SPECIAL NEEDS LOCKING

ARRANGEMENTS

Where special locking arrangements for the

safety needs of the patient are used, all of

K 0222

SS=F

Bldg. 01

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet of 37




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the Clinical or Security Locking requirements

are being met. In addition, the locks must be

electrical locks that fail safely so as to

release upon loss of power to the device; the

building is protected by a supervised

automatic sprinkler system and the locked

space is protected by a complete smoke

detection system (or is constantly monitored

at an attended location within the locked

space); and both the sprinkler and detection

systems are arranged to unlock the doors

upon activation.

18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4

DELAYED-EGRESS LOCKING

ARRANGEMENTS

Approved, listed delayed-egress locking

systems installed in accordance with

7.2.1.6.1 shall be permitted on door

assemblies serving low and ordinary hazard

contents in buildings protected throughout

by an approved, supervised automatic fire

detection system or an approved,

supervised automatic sprinkler system.

18.2.2.2.4, 19.2.2.2.4

ACCESS-CONTROLLED EGRESS

LOCKING ARRANGEMENTS

Access-Controlled Egress Door assemblies

installed in accordance with 7.2.1.6.2 shall

be permitted.

18.2.2.2.4, 19.2.2.2.4

ELEVATOR LOBBY EXIT ACCESS

LOCKING ARRANGEMENTS

Elevator lobby exit access door locking in

accordance with 7.2.1.6.3 shall be permitted

on door assemblies in buildings protected

throughout by an approved, supervised

automatic fire detection system and an

approved, supervised automatic sprinkler

system.

18.2.2.2.4, 19.2.2.2.4

Based on observation, record review, and

interview; the facility failed to ensure 3

K 0222 Colonial Nursing & Rehab Center

Summary of Deficiency Tags:11/01/2017 12:00:00AM





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of 11 exits had a code posted. LSC

19.2.2.2.4 requires doors within a

required means of egress shall not be

equipped with a latch or lock that

requires the use of a tool or key from the

egress side. LSC 19.2.2.2.5.2 requires

door-locking arrangements without

delayed egress shall be permitted in

health care occupancies, or portions of

health care occupancies, where the

clinical needs of the patients require

specialized security measures for their

safety, provided that staff can readily

unlock such doors at all times. This

deficient practice could affect all

occupants.

Findings include:

Based on observation with the

Maintenance Director on 10/02/17

between 9:34 a.m. and 9:58 a.m., the

entrance/exit doors were held in the

locked position with a magnetic hold

down device. Furthermore, the exit door

was equipped with an electronic keypad

entry system that allowed staff to open

the locked exit doors with a combination.

A code was not posted at the the

following entrance/exit doors:

a) by resident room 208

b) Dining room

c) Front Entrance

Based on an interview at the time of each

Life Safety Inspection October 2,

2017

1. K222/SS-F: Three door

locations did not have exit codes

posted (by resident room 208;

dining room and front entrance).

(A) What corrective action(s) will

be accomplished for those

residents found to have been

affected by the deficient practice:

On 10/3/17, Dir of Maintenance

posted codes on three (3) cited

doors.

(B) How other residents having

the potential to be affected by the

same deficient practice will be

identified and what corrective

actions will be taken: All residents

and staff assigned have the

potential to be affected by the

deficient practice. Dir of

Maintenance/Designee will do

monthly audits of these (3) door

code locations to insure

continued compliance. Audit will

be conducted for 6 months.

(C) What measures will be put

into place or what systemic

changes will be made to ensure

that the deficient practice does

not recur: Dir of


monthly audits of these (3) door

code locations to insure

continued compliance. Results

will be review by QA Committee

quarterly.

(D) How the corrective action(s)

will be monitored to ensure the





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observation, the Maintenance Director

acknowledged each aforementioned

condition and confirmed there was not a

clinical need to lock the doors.

3.1-19(b)

deficient practice will not recur,

i.e. what quality assurance

program will be put into place,

and: Corrective action is one

time and final fix. Status of

monthly audits to be discussed at

next scheduled QA meeting.

(E) What date will the systemic

changes be completed: Door

codes on (3) cited locations will

be corrected on/before 11-1-17.

Actual completion of codes for

cited doors was completed

10-3-17.

LSC Oct2017 POC K222

NFPA 101

Aisle, Corridor, or Ramp Width

Aisle, Corridor or Ramp Width

2012 EXISTING

The width of aisles or corridors (clear or

K 0232

SS=E

Bldg. 01





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unobstructed) serving as exit access shall

be at least 4 feet and maintained to provide

the convenient removal of nonambulatory

patients on stretchers, except as modified by

19.2.3.4, exceptions 1-5.

19.2.3.4, 19.2.3.5

Based on observation and interview, the

facility failed to meet 1 of 1 2nd floor

corridors clear width requirement

exception per 19.2.3.4(5). LSC

19.2.3.4(5) requires where the corridor

width is at least 8 feet, projections into

the required width shall be permitted for

fixed furniture. This deficient practice

could affect staff and up to 8 residents.

Findings include:


Maintenance Director on 10/02/17 at

9:35 a.m., a chair was located in the

corridor outside of North East Stairwell.

The corridor width was less than 8 feet

wide so the chair did not meet the

exception. Based on interview at the

time of observation, the Maintenance

Director acknowledged the chair would

be an impediment to egress.

3.1-19(b)


Summary of Deficiency Tags:


2017

1. K232/SS-E: Chair

removed from corridor outside

north east stairwell.





On 10/3/17, Dir of Maintenance

removed chair in corridor outside

north ease stairwell.





actions will be taken: Up to 10

residents and staff assigned have



Maintenance/Designee will

conduct staff inservice to insure

continued compliance.





not recur: Dir of


monthly audits of the second floor

corridor locations to insure the

11/01/2017 12:00:00AM





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absence of furniture outside the

north east stairwell. Results will

be review by QA Committee

quarterly.






and: Dir of

Maintenance/Designee to do

monthly audit of second floor

corridor outside the north east

stairwell for 6 months to insure

compliance. Results to be

reviewed at quarterly QA

meetings.


changes be completed: Inservice

to be completed on/before

11-1-17. Cited furniture removed

from north east stairwell area on

10-3-17.






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NFPA 101

Hazardous Areas - Enclosure

Hazardous Areas - Enclosure

2012 EXISTING

Hazardous areas are protected by a fire

barrier having 1-hour fire resistance rating

(with 3/4-hour fire rated doors) or an

automatic fire extinguishing system in

accordance with 8.7.1. When the approved

automatic fire extinguishing system option is

used, the areas shall be separated from

other spaces by smoke resisting partitions

and doors in accordance with 8.4. Doors

shall be self-closing or automatic-closing

and permitted to have nonrated or

field-applied protective plates that do not

exceed 48 inches from the bottom of the

door.

Describe the floor and zone locations of

hazardous areas that are deficient in

REMARKS.

19.3.2.1

Area Automatic Sprinkler

Seperation N/A

a. Boiler and Fuel-Fired Heater Rooms

b. Laundries (larger than 100 square feet)

c. Repair, Maintenance, and Paint Shops

d. Soiled Linen Rooms (exceeding 64

gallons)

e. Trash Collection Rooms

(exceeding 64 gallons)

f. Combustible Storage Rooms/Spaces

(over 50 square feet)

g. Laboratories (if classified as Severe

Hazard - see K3220)

K 0321

SS=E

Bldg. 01


facility failed to ensure 1 of 1 natural gas







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fuel fired Boiler room was protected in

accordance with 19.3.2. LSC 19.3.2,

Protection from Hazards. This deficient

practice could affect staff and up to 10

residents.

Findings include:



10:21 a.m., the Boiler room corridor door

self-closed but failed to completely latch

into the frame when tested. Based on

interview at the time of observation, the

Maintenance Director acknowledged the

corridor door failing to latch into the

frame.

3.1-19(b)


2017

1. K321/SS-E: Boiler room

door did not self- close when

tested.





Dir of Maintenance replaced door

lock and strike plate on door latch

on 10-11-17. Door now closes

properly on self -close test..






residents and staff assigned have


deficient practice. With door latch

corrections made this practice is

no longer a threat to residents of

staff..





not recur: Dir of

Maintenance/Designee will add

this door location to monthly audit

on K222. Audit to run 6 months

with results review by QA

Committee quarterly.










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and: Dir of


monthly audit as referenced in

para C above with results to be

reviewed at quarterly QA

meetings.


changes be completed: Work to

be completed on/before 11-1-17.

Modification to door latch

made/completed 10-11-17.


NFPA 101

Cooking Facilities

Cooking Facilities

Cooking equipment is protected in

accordance with NFPA 96, Standard for

Ventilation Control and Fire Protection of

Commercial Cooking Operations, unless:

* residential cooking equipment (i.e., small

appliances such as microwaves, hot plates,

K 0324

SS=D

Bldg. 01





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toasters) are used for food warming or

limited cooking in accordance with

18.3.2.5.2, 19.3.2.5.2

* cooking facilities open to the corridor in

smoke compartments with 30 or fewer

patients comply with the conditions under

18.3.2.5.3, 19.3.2.5.3, or

* cooking facilities in smoke compartments

with 30 or fewer patients comply with

conditions under 18.3.2.5.4, 19.3.2.5.4.

Cooking facilities protected according to

NFPA 96 per 9.2.3 are not required to be

enclosed as hazardous areas, but shall not

be open to the corridor.

18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1

through 19.3.2.5.5, 9.2.3, TIA 12-2

1. Based on observation and interview,

the facility failed to ensure staff were

instructed in the use of the UL 300 hood

system in 1 of 1 Kitchen. NFPA 96,

11.1.4 states instructions for manually

operating the fire extinguishing system

shall be posted conspicuously in the

kitchen and shall be reviewed with

employees by management. This

deficient practice could affect staff only.

Findings include:



10:24 a.m., the Kitchen contained a UL

300 hood system. Based on interview, a

staff member was asked what she would

do if there was a fire underneath the

hood. She replied she would grab the K

class fire extinguisher and that was it.




2017

1. K324/SS-D: Kitchen staff

did not respond correctly when

asked what to do if there was a

fire underneath the hood; PULL

sign placard not installed on K

class wall mounted fire

extinguisher; and 2nd quarter

hood/duct inspection was out of

date





Dir of Maintenance to conduct

kitchen staff inservice on proper

operation of the hood

extinguishing system PULL

device. New PULL placard will be

installed above existing PULL

knob on currently installed

equipment.

11/01/2017 12:00:00AM





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She failed to indicate pulling the hood

pull station. Based on interview, the

Maintenance Director acknowledged her

response and confirmed that he will

instruct all kitchen staff on proper

response.

3.1-19(b)

2. Based on record review and interview,

the facility failed to ensure 1 of 1 kitchen

exhaust system was completely

maintained. NFPA 96, Standard for

Ventilation Control and Fire Protection

of Commercial Cooking Operations,

2011 Edition at 11.2.1 maintenance of

the fire-extinguishing systems and listed

exhaust hoods containing a constant or

fire-activated water system that is listed

to extinguish a fire in the grease removal

devices, hood exhaust plenums, and

exhaust ducts shall be made by properly

trained, qualified, and certified person(s)

acceptable to the authority having

jurisdiction at least every 6 months. This


Findings include:

Based on record review with the


9:05 a.m., the kitchen hood testing for the

last twelve months was only performed

once on 02/02/17 by Allied Safety.





actions will be taken: This

deficient practice will affect only

kitchen staff assigned each shift.

Additional PULL placard/sign to

be installed on/before 11-1-17.





not recur: Adding the new PULL

placard is a once and final

remedy. Kitchen staff and Food

Service Manager will be

responsible for daily monitoring of

presence of placard. The 2nd

quarter hood inspection was

delayed due to a vendor change

and unpredicted labor strike in

that organization. Now that strike

is over all quarterly inspections

will be made timely. Dir of

Maintenance to insure vendor

performance quarterly.






and: Dir of


monthly audits for 6 months on

presence of PULL placard on wall

mounted extinguisher unit and

timely inspections on quarterly

hood inspections .





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Based on interview at the time of record

review, the Maintenance Director

acknowledged the hood inspection should

have been performed six months after the

last inspection.

3.1-19(b)

3. Based on observation and interview,

the facility failed to ensure 1 of 1 Kitchen

placard was installed. NFPA 96,

Standard for Ventilation Control and Fire

Protection of Commercial Cooking

Operations, 2011 Edition 10.2.2* A

placard shall be conspicuously placed

near each extinguisher that states that the

fire protection system shall be activated

prior to using the fire extinguisher. This


Findings include:



10:24 a.m., the Kitchen did not have a

placard installed near the K class fire

extinguisher indicating staff that the fire

protection system shall be activated prior

to using the fire extinguisher. Based on



lack of signage.

3.1-19(b)


changes be completed: 11-1-17.






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NFPA 101

Fire Alarm System - Out of Service

Fire Alarm - Out of Service

Where required fire alarm system is out of

services for more than 4 hours in a 24-hour

period, the authority having jurisdiction shall

be notified, and the building shall be

evacuated or an approved fire watch shall

be provided for all parties left unprotected by

the shutdown until the fire alarm system has

been returned to service.

9.6.1.6

K 0346

SS=C

Bldg. 01

Based on record review and interview,

the facility failed to provide a complete

written policy for the protection of

residents indicating procedures to be

followed in the event the fire alarm

system has to be placed out of service for

four hours or more in a twenty four hour

period in accordance with LSC, Section

9.6.1.6. This deficient practice affects all

occupants.

Findings include:



9:06 a.m., the facility provided fire watch

documentation but it was incomplete.

The plan failed to include contacting the

Indiana State Department of Health via

the Web Portal. Based on an interview

record review, the Maintenance Director

acknowledged fire watch policy failed to

include the web link for contacting the

Incident Reporting System located on the




2017

1. K346/SS-C. Fire watch

documentation was incomplete

and failed to include staff

responsibility for contacting ISDH

via Gateway web portal.





Administrator will be responsible

for revising fire watch

policy/procedure to insure staff

contact ISDH via Gateway web

portal. During day shift

occurrences, the Dir of

Maintenance will contact ISDH via

the web portal. If fire emergency

occurs after normal business

hours, the B-Hall Charge Nurse

will be responsible for notifying

ISDH via web portal. All

residents and staff have the

potential to be affected by this

deficiency.

11/01/2017 12:00:00AM





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Indiana State Department of Health

(ISDH) Gateway.

3.1-19(b)





actions will be taken: All

residents could be affected by

this deficient practice. Written fire

watch plan will be revised to

indicate staff responsibility for

notifying ISDH via web portal

during fire watch conditions.





not recur: Administrator will

rewrite documentation in fire

watch policy to reflect staff

notification to ISDH via web portal

be done by Director of

Maintenance (normal business

hours) or B-Hall Charge Nurse

after normal business hours.






and: Dir of


nursing staff inservice for charge

nurses so they understand the

policy revision to notify ISDH via

web portal if fire watch conditions

occur during their shift after

normal business hours.







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NFPA 101

Sprinkler System - Installation

Spinkler System - Installation

2012 EXISTING

Nursing homes, and hospitals where

required by construction type, are protected

throughout by an approved automatic

sprinkler system in accordance with NFPA

13, Standard for the Installation of Sprinkler

Systems.

In Type I and II construction, alternative

protection measures are permitted to be

substituted for sprinkler protection in specific

areas where state or local regulations

prohibit sprinklers.

In hospitals, sprinklers are not required in

clothes closets of patient sleeping rooms

where the area of the closet does not

exceed 6 square feet and sprinkler coverage

covers the closet footprint as required by

NFPA 13, Standard for Installation of

Sprinkler Systems.

19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4,

K 0351

SS=F

Bldg. 01





10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155733 10/02/2017


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01

19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)


facility failed to ensure a complete

automatic sprinkler system was installed

in accordance with 19.3.5.1. NFPA 13,

2010 Edition, Standard for the

Installation of Sprinkler Systems, Section

9.1.1.7, Support of Non-System

Components, requires sprinkler piping or

hangers shall not be used to support

non-system components. This deficient

practice could affect all occupants.

Findings include:

Based on observations with the


9:36 a.m., an Ethernet cable was zip tied

to the sprinkler line outside of resident

room 208. Based on interview at the

time of observation, the Maintenance

Director acknowledged the wire secured

to the sprinkler pipe.

3.1-19(b)




2017

1. K351/SS-F. Ethernet

cable was zip tied to sprinkler line

outside room 208.





All residents and staff have the


deficient practice. On Oct 4,

2017, facility internet vendor

removed cable from sprinkler line

and rerouted cable above the

ceiling.







this deficient practice. This was

only area where Ethernet cable

was seen to be improperly

connected. The repair/correction

was a onetime occurrence and

will not recur.





not recur: Dir of Maintenance will

monitor sprinkler lines for

absence of internet cable during

11/01/2017 12:00:00AM





10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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current monthly sprinkler line

checks as part of the periodic

maintenance program.






and: Dir of

Maintenance/Designee will report

monthly sprinkler line checks to

the QA Committee quarterly.




NFPA 101

Sprinkler System - Maintenance and Testing

Sprinkler System - Maintenance and Testing

Automatic sprinkler and standpipe systems

are inspected, tested, and maintained in

accordance with NFPA 25, Standard for the

Inspection, Testing, and Maintaining of

K 0353

SS=F

Bldg. 01





10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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Water-based Fire Protection Systems.

Records of system design, maintenance,

inspection and testing are maintained in a

secure location and readily available.

a) Date sprinkler system last checked

_____________________

b) Who provided system test

____________________________

c) Water system supply source

__________________________

Provide in REMARKS information on

coverage for any non-required or partial

automatic sprinkler system.

9.7.5, 9.7.7, 9.7.8, and NFPA 25


the facility failed to maintain 1 of 1

sprinkler system in accordance with LSC

9.7.5. LSC 9.7.5 requires all automatic

sprinkler systems shall be inspected and

maintained in accordance with NFPA 25,

Standard for the Inspection, Testing, and

Maintenance of Water-Based Fire

Protection Systems. NFPA 25, 2011

edition, Table 5.1.1.2 indicates the

required frequency of inspection and

testing. This deficient practice could

affect all occupants.

Findings include:



9:23 a.m., no documentation was

available for the second quarterly

inspection, monthly control valves, and

monthly wet system gauge inspection.

Based on interview at the time of record




2017

1. K353/SS-F.

Documentation was not available

for the 2nd quarterly inspection,

monthly control valves and

monthly wet system gauge

inspection.







deficient practice. The 2nd

quarter inspection was delayed

due to a labor strike. Inspection

was conducted August 25, 2017.







11/01/2017 12:00:00AM





10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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review, the Maintenance Director

acknowledged the lack of documentation.

3.1-19(b)

this deficient practice. Dir of

Maintenance will monitor

quarterly inspection performance

by vendor to insure compliance.






monitor quarterly inspection

schedule by new vendor and

report to administration if vendor

is non-compliant.






and: Dir of

Maintenance/Designee will report

quarterly sprinkler system

maintenance inspection

compliance to the QA Committee

quarterly.








10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

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NFPA 101

Sprinkler System - Out of Service

Sprinkler System - Out of Service

Where the sprinkler system is impaired, the

extent and duration of the impairment has

been determined, areas or buildings

involved are inspected and risks are

determined, recommendations are

submitted to management or designated

representative, and the fire department and

other authorities having jurisdiction have

been notified. Where the sprinkler system is

out of service for more than 10 hours in a

24-hour period, the building or portion of the

building affected are evacuated or an

approved fire watch is provided until the

sprinkler system has been returned to

service.

18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

K 0354

SS=C

Bldg. 01


the facility failed to provide a complete

written policy containing procedures to

be followed in the event the automatic


Life Safety Code (LSC) Survey

–October 2, 2017


1. K-354/SS/C:

11/01/2017 12:00:00AM





10/26/2017PRINTED:

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OMB NO. 0938-0391




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TAG



DEFICIENCY)

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sprinkler system has to be placed

out-of-service for 10 hours or more in a

24-hour period in accordance with LSC,

Section 9.7.5. LSC 9.7.5 requires

sprinkler impairment procedures comply

with NFPA 25, 2011 Edition, the

Standard for the Inspection, Testing and

Maintenance of Water-Based Fire

Protection Systems. NFPA 25, 15.5.2

requires nine procedures that the

impairment coordinator shall follow.

This deficient practice could affect all

occupants.

Findings include:



9:06 a.m., the facility provided fire watch

documentation but it was incomplete.

The plan failed to include contacting the

Indiana State Department of Health via

the Web Portal. Based on an interview

record review, the Maintenance Director

acknowledged fire watch policy failed to

include the web link for contacting the

Incident Reporting System located on the

Indiana State Department of Health

(ISDH) Gateway.

3.1-19(b)

Documentation on fire watch

plan was incomplete as it failed to

include staff contacting the ISDH

via the Gateway web portal.







deficient practice. Administrator

will be responsible for revising the

fire watch policy/procedure to

insure staff contact ISDH via the

Gateway web portal. During day

shift occurrences, the Dir of






ISDH via the web portal.








deficient practice. Written fire














10/26/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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be done by Dir of Maintenance

(during normal business hours) or

B-Hall Charge Nurse (after

normal business hours).






and: Dir of



nurses to they understand the

policy to notify ISDH via web

portal if fire watch conditions










10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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01

NFPA 101

Subdivision of Building Spaces - Smoke

Barrie

Subdivision of Building Spaces - Smoke

Barrier Construction

2012 EXISTING

Smoke barriers shall be constructed to a

1/2-hour fire resistance rating per 8.5.

Smoke barriers shall be permitted to

terminate at an atrium wall. Smoke dampers

are not required in duct penetrations in fully

ducted HVAC systems where an approved

sprinkler system is installed for smoke

compartments adjacent to the smoke

barrier.

19.3.7.3, 8.6.7.1(1)

Describe any mechanical smoke control

system in REMARKS.

K 0372

SS=E

Bldg. 01


facility failed to ensure the penetrations

caused by the passage of wire and/or

conduit through 1 of 2 smoke barrier

walls were protected to maintain the

smoke resistance of each smoke barrier.

LSC Section 19.3.7.5 requires smoke

barriers to be constructed in accordance

with LSC Section 8.5 and shall have a

minimum ½ hour fire resistive rating.

This deficient practice could affect staff


Life Safety Code (LSC) Survey –

October 2, 2017

Summary of Deficiency Tag:

1. K372 – S/S E: Four (4)

separate unsealed penetrations

ranging from a quarter inch to a

half inch were discovered in the

basement smoke barrier.

(A) What corrective action(s)

will be accomplished for those


11/01/2017 12:00:00AM





10/26/2017PRINTED:

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OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG




PREFIX

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DEFICIENCY)

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and at least 10 residents.

Findings include:



10:30 a.m., four separate unsealed

penetrations ranging from a quarter inch

to a half inch was discovered in the

Basement smoke barrier. Based on


Maintenance Director acknowledged

each aforementioned condition and

provided the measurements.

3.1-19(b)





Maintenance closed the four (4)

noted unsealed penetrations in

the basement smoke barrier on

October 3, 2017.






residents/staff have the potential

to be affected by this deficient

practice. Once the penetrations

were sealed on October 3, 2017,

the hazard was eliminated and

deficiency corrected.





not recur: The penetrations cited

were the only ones out of

compliance. Openings were

corrected/closed on October 3,

2017.






and: The Maintenance Director

has sealed the penetrations on

October 3, 2017. No additional

monitoring need be done unless

the facility needed contractor

work to run wiring thru smoke





10/26/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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barriers in the future. In that

event, the Dir of Maintenance

would follow up and insure all

penetrations were properly

sealed. Results of that action

would be reported to the QA

Committee.

(E) By what date will the

systemic changes be completed:

11-1-2017.






10/26/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG




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TAG



DEFICIENCY)

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NFPA 101

Evacuation and Relocation Plan

Evacuation and Relocation Plan

There is a written plan for the protection of

all patients and for their evacuation in the

event of an emergency.

Employees are periodically instructed and

kept informed with their duties under the

plan, and a copy of the plan is readily

available with telephone operator or with

security. The plan addresses the basic

response required of staff per 18/19.7.2.1.2

and provides for all of the fire safety plan

components per 18/19.2.2.

18.7.1.1 through 18.7.1.3, 18.7.2.1.2,

18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3,

19.7.2.1.2, 19.7.2.2, 19.7.2.3

K 0711

SS=C

Bldg. 01


the facility failed to provide a written

plan that addressed all components in 1

of 1 written fire plan. LSC 19.7.2.2

requires a written health care occupancy

fire safety plan that shall provide for the

following:

(1) Use of alarms

(2) Transmission of alarm to fire

department

(3) Emergency phone call to fire

department

(4) Response to alarms

(5) Isolation of fire

(6) Evacuation of immediate area

(7) Evacuation of smoke compartment

(8) Preparation of floors and building for

evacuation



–October 2, 2017


1. K-354/SS/C:

Documentation on fire watch

plan was incomplete as it failed to

include staff contacting the ISDH

via the Gateway web portal.







deficient practice. Administrator

will be responsible for revising the

fire watch policy/procedure to

insure staff contact ISDH via the

Gateway web portal. During day

shift occurrences, the Dir of

11/01/2017 12:00:00AM





10/26/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

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(9) Extinguishment of fire

This deficient practice could affect all

occupants.

Findings include:

Based on a record review and interview

on 10/02/17 at 9:06 a.m., the


"Fire Safety / Fire Response" did not

address (3) Emergency phone call to fire

department.

3.1-19(b)






ISDH via the web portal.








deficient practice. Written fire













be done by Dir of Maintenance

(during normal business hours) or

B-Hall Charge Nurse (after

normal business hours).






and: Dir of



nurses to they understand the





10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

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policy to notify ISDH via web

portal if fire watch conditions






NFPA 101

Smoking Regulations

Smoking Regulations

Smoking regulations shall be adopted and

shall include not less than the following

provisions:

K 0741

SS=D

Bldg. 01





10/26/2017PRINTED:

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OMB NO. 0938-0391




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B. WING

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(X4) ID

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TAG



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(1) Smoking shall be prohibited in any room,

ward, or compartment where flammable

liquids, combustible gases, or oxygen is

used or stored and in any other hazardous

location, and such area shall be posted with

signs that read NO SMOKING or shall be

posted with the international symbol for no

smoking.

(2) In health care occupancies where

smoking is prohibited and signs are

prominently placed at all major entrances,

secondary signs with language that prohibits

smoking shall not be required.

(3) Smoking by patients classified as not

responsible shall be prohibited.

(4) The requirement of 18.7.4(3) shall not

apply where the patient is under direct

supervision.

(5) Ashtrays of noncombustible material and

safe design shall be provided in all areas

where smoking is permitted.

(6) Metal containers with self-closing cover

devices into which ashtrays can be emptied

shall be readily available to all areas where

smoking is permitted.

18.7.4, 19.7.4


facility failed to ensure 1 of 1 area where

smoking was permitted for staff and

residents was maintained in accordance

with 19.7.4. LSC 19.7.4 requires

ashtrays of noncombustible material and

safe design shall be provided in all areas

where smoking is permitted. Metal

containers with a self-closing cover

devices into which ashtrays can be

emptied shall be readily available to all

areas were smoking is permitted. This




–October 2, 2017


1. K-741/SS/D: The (ouside)

staff smoking area contained a

long neck smoking oasis. The

long neck smoking oasis was

missing the top portion so at least

30 cigarette butts were not

contained with a lid.





11/01/2017 12:00:00AM





10/26/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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Findings include:



10:06 a.m., the staff smoking area

contained a long neck smoking oasis.

The long neck smoking oasis was

missing the top portion so at least 30

cigarette butts were not contained with a

lid. Based on interview at the time of

observation, the Maintenance Director

acknowledged the missing portion of the

long neck smoking oasis.

3.1-19(b)

Staff who smoke have the



Maintenance ordered lidded

smoke butt receptacles which

were received October 4, 2017

and put in place at the outside

staff smoking area.





actions will be taken: All staff who

smoke have the potential to be

affected by the deficient practice.

Staff will be reminded of the

designated smoking area and

proper use of the smoking

receptacles in place. Dir of

Maintenance/Designee make

daily rounds outside to keep

watch on cigarette disposal in the

lidded cans.





not recur: Dir of


monitor smoking area regularly

for proper use of smoking can

receptacle.






and: Dir of





10/26/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG



DEFICIENCY)

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monthly recap of smoking area

compliance and report to QA

Committee for 6 months.




NFPA 101

Combustible Decorations

Combustible Decorations

Combustible decorations shall be prohibited

unless one of the following is met:

* Flame retardant or treated with approved

fire-retardant coating that is listed and

labeled for product.

K 0753

SS=E

Bldg. 01





10/26/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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* Decorations meet NFPA 701.

* Decorations exhibit heat release less than

100 kilowatts in accordance with NFPA 289.

* Decorations, such as photographs,

paintings and other art are attached to the

walls, ceilings and non-fire-rated doors in

accordance with 18.7.5.6 or 19.7.5.6.

* The decorations in existing occupancies

are in such limited quantities that a hazard of

fire is not present.

18.7.5.6, 19.7.5.6


facility failed to ensure 1 of 1 Activities

room was maintained in accordance with

19.7.5.6. LSC 19.7.5.6 prohibits

combustible decorations unless an

exception was met. This deficient

practice could affect staff and up to 14

residents.

Findings include:



10:15 a.m., the Activities room contained

a candle with a wick. Based on interview

at the time of observation, the


wick inside the candle.

3.1-19(b)




2017

1. K753/SS-E. The activities

room contained a candle with a

wick.








Maintenance immediately

removed the candle with the wick

on October 2, 2017, during the

survey.







this deficient practice.

Administrator to notify Dir of Life

Enrichment/Activities of

prohibition against using live

candles with wicks in the planning

11/01/2017 12:00:00AM





10/26/2017PRINTED:

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OMB NO. 0938-0391




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of resident activities. Dir of

Maintenance to inservice activity

staff on appropriate use of

mechanical candles with no

wicks.





not recur: Dir of Maintenance has

removed the source of the

deficiency and it will not recur.

Dir of Maintenance will also

reeducate activity staff on

restrictions against using live

candles during events.






and: Dir of Life

Enrichment/Activities will take

precautions against use of live

candles with wicks and only use

mechanical/electrical candles as

needed for events especially

during holiday periods.








10/26/2017PRINTED:

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OMB NO. 0938-0391




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DEFICIENCY)

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NFPA 101

Electrical Equipment - Power Cords and

Extens

Electrical Equipment - Power Cords and

Extension Cords

Power strips in a patient care vicinity are

only used for components of movable

patient-care-related electrical equipment

(PCREE) assembles that have been

assembled by qualified personnel and meet

the conditions of 10.2.3.6. Power strips in

the patient care vicinity may not be used for

non-PCREE (e.g., personal electronics),

except in long-term care resident rooms that

do not use PCREE. Power strips for PCREE

meet UL 1363A or UL 60601-1. Power

strips for non-PCREE in the patient care

rooms (outside of vicinity) meet UL 1363. In

non-patient care rooms, power strips meet

other UL standards. All power strips are

used with general precautions. Extension

cords are not used as a substitute for fixed

wiring of a structure. Extension cords used

temporarily are removed immediately upon

completion of the purpose for which it was

installed and meets the conditions of 10.2.4.

10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99),

400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA

12-5

K 0920

SS=E

Bldg. 01

Based on observation, record review, and

interview; the facility failed to install 1 of







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1 power strip according to 9.1.2. LSC

9.1.2 requires electrical wiring and

equipment shall be in accordance with

NFPA 70, National Electrical Code.

NFPA 70, 2011 Edition, Article 110.3(B)

Installation and Use, states listed or

labeled equipment shall be installed and

used in accordance with any instructions

included in the listing or labeling. This

deficient practice affects staff and up to

22 residents.

Findings include:



9:43 a.m., a lamp outlet was powering a

nebulizer in resident room 112. Based on



medical equipment into the lamp outlet

extension cord.

3.1-19(b)


2017

1. K920/SS-E. In room 112,

a nebulizer was being powered by

a cord connected to a lamp outlet

extension cord.





Up to 22 residents and staff have

the potential to be affected by this

deficient practice. On date of

survey, Dir of Maintenance

reconnected the nebulizer into a

dedicated wall outlet.






residents and staff could be

affected by this deficient practice.

Dir of Maintenance will inservice

nursing staff on proper

connection of electrical

equipment into dedicated wall

outlets and not extension cords.






inservice nursing staff on how to

connect nebulizers or any other

equipment needing electrical

power.





10/26/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



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and: Dir of


conduct random monthly audits of

resident rooms with medical

equipment to verify proper use of

dedicated wall outlets for power.





printed: 10/26/2017 department of health and …the locked exit doors with a combination. a code was...

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