Post on 17-Jun-2021
(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 Page 1 of 37
(X6) DATE
(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
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 Page 2 of 37
(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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 3 of 37
(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
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
Maintenance/Designee will do
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 4 of 37
(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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 5 of 37
(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
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:
Based on observation with the
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)
K 0232 Colonial Nursing & Rehab Center
Summary of Deficiency Tags:
Life Safety Inspection October 2,
2017
1. K232/SS-E: Chair
removed from corridor outside
north east stairwell.
(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
removed chair in corridor outside
north ease stairwell.
(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: Up to 10
residents and staff assigned have
the potential to be affected by the
deficient practice. Dir of
Maintenance/Designee will
conduct staff inservice to insure
continued compliance.
(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
Maintenance/Designee will do
monthly audits of the second floor
corridor locations to insure the
11/01/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 6 of 37
(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
absence of furniture outside the
north east stairwell. Results will
be review by QA Committee
quarterly.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
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.
(E) What date will the systemic
changes be completed: Inservice
to be completed on/before
11-1-17. Cited furniture removed
from north east stairwell area on
10-3-17.
LSC Oct2017 POC K232
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 7 of 37
(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
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
Based on observation and interview, the
facility failed to ensure 1 of 1 natural gas
K 0321 Colonial Nursing & Rehab Center
Summary of Deficiency Tags:11/01/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 8 of 37
(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
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:
Based on observation with the
Maintenance Director on 10/02/17 at
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)
Life Safety Inspection October 2,
2017
1. K321/SS-E: Boiler room
door did not self- close when
tested.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
Dir of Maintenance replaced door
lock and strike plate on door latch
on 10-11-17. Door now closes
properly on self -close test..
(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: Up to 10
residents and staff assigned have
the potential to be affected by the
deficient practice. With door latch
corrections made this practice is
no longer a threat to residents of
staff..
(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
Maintenance/Designee will add
this door location to monthly audit
on K222. Audit to run 6 months
with results review by QA
Committee quarterly.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 9 of 37
(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
and: Dir of
Maintenance/Designee to do
monthly audit as referenced in
para C above with results to be
reviewed at quarterly QA
meetings.
(E) What date will the systemic
changes be completed: Work to
be completed on/before 11-1-17.
Modification to door latch
made/completed 10-11-17.
LSC Oct2017 POC K321
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 10 of 37
(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
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:
Based on observation with the
Maintenance Director on 10/02/17 at
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.
K 0324 Colonial Nursing & Rehab Center
Summary of Deficiency Tags:
Life Safety Inspection October 2,
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
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 11 of 37
(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
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
deficient practice could affect staff only.
Findings include:
Based on record review with the
Maintenance Director on 10/02/17 at
9:05 a.m., the kitchen hood testing for the
last twelve months was only performed
once on 02/02/17 by Allied Safety.
(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: This
deficient practice will affect only
kitchen staff assigned each shift.
Additional PULL placard/sign to
be installed on/before 11-1-17.
(C) What measures will be put
into place or what systemic
changes will be made to ensure
that the deficient practice does
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.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
and: Dir of
Maintenance/Designee to do
monthly audits for 6 months on
presence of PULL placard on wall
mounted extinguisher unit and
timely inspections on quarterly
hood inspections .
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 12 of 37
(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
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
deficient practice could affect staff only.
Findings include:
Based on observation with the
Maintenance Director on 10/02/17 at
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
interview at the time of observation, the
Maintenance Director acknowledged the
lack of signage.
3.1-19(b)
(E) What date will the systemic
changes be completed: 11-1-17.
LSC Oct2017 POC K324
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 13 of 37
(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
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:
Based on record review with the
Maintenance Director on 10/02/17 at
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
K 0346 Colonial Nursing & Rehab Center
Summary of Deficiency Tags:
Life Safety Inspection October 2,
2017
1. K346/SS-C. Fire watch
documentation was incomplete
and failed to include staff
responsibility for contacting ISDH
via Gateway web portal.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 14 of 37
(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
Indiana State Department of Health
(ISDH) Gateway.
3.1-19(b)
(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 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.
(C) What measures will be put
into place or what systemic
changes will be made to ensure
that the deficient practice does
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.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
and: Dir of
Maintenance/Designee to do
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.
(E) What date will the systemic
changes be completed: 11-1-17.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 15 of 37
(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
LSC Oct2017 POC K346
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 16 of 37
(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
19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Based on observation and interview, the
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
Maintenance Director on 10/02/17 at
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)
K 0351 Colonial Nursing & Rehab Center
Summary of Deficiency Tags:
Life Safety Inspection October 2,
2017
1. K351/SS-F. Ethernet
cable was zip tied to sprinkler line
outside room 208.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
All residents and staff have the
potential to be affected by this
deficient practice. On Oct 4,
2017, facility internet vendor
removed cable from sprinkler line
and rerouted cable above the
ceiling.
(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 could be affected by
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.
(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 Maintenance will
monitor sprinkler lines for
absence of internet cable during
11/01/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 17 of 37
(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
current monthly sprinkler line
checks as part of the periodic
maintenance program.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
and: Dir of
Maintenance/Designee will report
monthly sprinkler line checks to
the QA Committee quarterly.
(E) What date will the systemic
changes be completed: 11-1-17.
LSC Oct2017 POC K351
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 18 of 37
(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
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
Based on record review and interview,
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:
Based on record review with the
Maintenance Director on 10/02/17 at
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
K 0353 Colonial Nursing & Rehab Center
Summary of Deficiency Tags:
Life Safety Inspection October 2,
2017
1. K353/SS-F.
Documentation was not available
for the 2nd quarterly inspection,
monthly control valves and
monthly wet system gauge
inspection.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
All residents and staff have the
potential to be affected by this
deficient practice. The 2nd
quarter inspection was delayed
due to a labor strike. Inspection
was conducted August 25, 2017.
(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 could be affected by
11/01/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 19 of 37
(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
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.
(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 Maintenance will
monitor quarterly inspection
schedule by new vendor and
report to administration if vendor
is non-compliant.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
and: Dir of
Maintenance/Designee will report
quarterly sprinkler system
maintenance inspection
compliance to the QA Committee
quarterly.
(E) What date will the systemic
changes be completed: 11-1-17.
LSC Oct2017 POC K353
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 20 of 37
(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
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
Based on record review and interview,
the facility failed to provide a complete
written policy containing procedures to
be followed in the event the automatic
K 0354 Colonial Nursing & Rehab Center
Life Safety Code (LSC) Survey
–October 2, 2017
Summary of Deficiency Tags:
1. K-354/SS/C:
11/01/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 21 of 37
(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
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:
Based on record review with the
Maintenance Director on 10/02/17 at
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.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
All residents and staff have the
potential to be affected by this
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
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 the web portal.
(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. Written fire
watch plan will be revised to
indicate staff responsibility for
notifying ISDH via web portal
during fire watch conditions.
(C) What measures will be put
into place or what systemic
changes will be made to ensure
that the deficient practice does
not recur: Administrator will
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 22 of 37
(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
rewrite documentation in fire
watch policy to reflect staff
notification to ISDH via web portal
be done by Dir of Maintenance
(during normal business hours) or
B-Hall Charge Nurse (after
normal business hours).
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
and: Dir of
Maintenance/Designee to do
nursing staff inservice for charge
nurses to they understand the
policy to notify ISDH via web
portal if fire watch conditions
occur during their shift after
normal business hours.
(E) What date will the systemic
changes be completed: 11-1-17.
LSC Oct2017 POC K354
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 23 of 37
(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
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
Based on observation and interview, the
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
K 0372 Colonial Nursing & Rehab Center
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
residents found to have been
11/01/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 24 of 37
(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
and at least 10 residents.
Findings include:
Based on observation with the
Maintenance Director on 10/02/17 at
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
interview at the time of observation, the
Maintenance Director acknowledged
each aforementioned condition and
provided the measurements.
3.1-19(b)
affected by the deficient practice:
All residents and staff have the
potential to be affected by this
deficient practice. Dir of
Maintenance closed the four (4)
noted unsealed penetrations in
the basement smoke barrier on
October 3, 2017.
(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/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.
(C) What measures will be put
into place or what systemic
changes will be made to ensure
that the deficient practice does
not recur: The penetrations cited
were the only ones out of
compliance. Openings were
corrected/closed on October 3,
2017.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 25 of 37
(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
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.
LSC Oct2017 POC K372
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 26 of 37
(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
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
Based on record review and interview,
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
K 0711 Colonial Nursing & Rehab Center
Life Safety Code (LSC) Survey
–October 2, 2017
Summary of Deficiency Tags:
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.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
All residents and staff have the
potential to be affected by this
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 27 of 37
(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
(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
Maintenance Director acknowledged the
"Fire Safety / Fire Response" did not
address (3) Emergency phone call to fire
department.
3.1-19(b)
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 the web portal.
(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. Written fire
watch plan will be revised to
indicate staff responsibility for
notifying ISDH via web portal
during fire watch conditions.
(C) What measures will be put
into place or what systemic
changes will be made to ensure
that the deficient practice does
not recur: Administrator will
rewrite documentation in fire
watch policy to reflect staff
notification to ISDH via web portal
be done by Dir of Maintenance
(during normal business hours) or
B-Hall Charge Nurse (after
normal business hours).
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
and: Dir of
Maintenance/Designee to do
nursing staff inservice for charge
nurses to they understand the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 28 of 37
(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
policy to notify ISDH via web
portal if fire watch conditions
occur during their shift after
normal business hours.
(E) What date will the systemic
changes be completed: 11-1-17.
LSC Oct2017 POC K711
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 29 of 37
(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
(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
Based on observation and interview, the
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
deficient practice could affect staff only.
K 0741 Colonial Nursing & Rehab Center
Life Safety Code (LSC) Survey
–October 2, 2017
Summary of Deficiency Tags:
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.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
11/01/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 30 of 37
(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
Findings include:
Based on observation with the
Maintenance Director on 10/02/17 at
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
potential to be affected by this
deficient practice. Dir of
Maintenance ordered lidded
smoke butt receptacles which
were received October 4, 2017
and put in place at the outside
staff smoking area.
(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 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.
(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
Maintenance/Designee will
monitor smoking area regularly
for proper use of smoking can
receptacle.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
and: Dir of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 31 of 37
(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
Maintenance/Designee to do
monthly recap of smoking area
compliance and report to QA
Committee for 6 months.
(E) What date will the systemic
changes be completed: 11-1-17.
LSC Oct2017 POC K741
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 32 of 37
(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
* 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
Based on observation and interview, the
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:
Based on observation with the
Maintenance Director on 10/02/17 at
10:15 a.m., the Activities room contained
a candle with a wick. Based on interview
at the time of observation, the
Maintenance Director acknowledged the
wick inside the candle.
3.1-19(b)
K 0753 Colonial Nursing & Rehab Center
Summary of Deficiency Tags:
Life Safety Inspection October 2,
2017
1. K753/SS-E. The activities
room contained a candle with a
wick.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
All residents and staff have the
potential to be affected by this
deficient practice. Dir of
Maintenance immediately
removed the candle with the wick
on October 2, 2017, during the
survey.
(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 could be affected by
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 33 of 37
(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
of resident activities. Dir of
Maintenance to inservice activity
staff on appropriate use of
mechanical candles with no
wicks.
(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 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.
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
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.
(E) What date will the systemic
changes be completed: 11-1-17.
LSC Oct2017 POC K753
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 34 of 37
(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
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
K 0920 Colonial Nursing & Rehab Center
Summary of Deficiency Tags:11/01/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 35 of 37
(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
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:
Based on observation with the
Maintenance Director on 10/02/17 at
9:43 a.m., a lamp outlet was powering a
nebulizer in resident room 112. Based on
interview at the time of observation, the
Maintenance Director acknowledged the
medical equipment into the lamp outlet
extension cord.
3.1-19(b)
Life Safety Inspection October 2,
2017
1. K920/SS-E. In room 112,
a nebulizer was being powered by
a cord connected to a lamp outlet
extension cord.
(A) What corrective action(s) will
be accomplished for those
residents found to have been
affected by the deficient practice:
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.
(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: Up to 22
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.
(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 Maintenance will
inservice nursing staff on how to
connect nebulizers or any other
equipment needing electrical
power.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 36 of 37
(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
(D) How the corrective action(s)
will be monitored to ensure the
deficient practice will not recur,
i.e. what quality assurance
program will be put into place,
and: Dir of
Maintenance/Designee will
conduct random monthly audits of
resident rooms with medical
equipment to verify proper use of
dedicated wall outlets for power.
(E) What date will the systemic
changes be completed: 11-1-17.
LSC Oct2017 POC K920
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RICB21 Facility ID: 000360 If continuation sheet Page 37 of 37