PRINTED: 02/25/2020 DEPARTMENT OF HEALTH AND HUMAN ...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

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 COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

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DEFICIENCY)

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DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46237

155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

--

E 0000

Bldg. --

An Emergency Preparedness Survey was

conducted by the Indiana State Department of

Health in accordance with 42 CFR 483.73.

Survey Date: 01/28/20

Facility Number: 0011149

Provider Number: 155757

AIM Number: 200829340

At this Emergency Preparedness survey,

Rosegate Village was found in compliance with

Emergency Preparedness Requirements for

Medicare and Medicaid Participating Providers

and Suppliers, 42 CFR 483.73.

The facility has 150 certified beds. At the time of

the survey, the census was 138.

Quality Review completed on 02/04/20

E 0000 RGV Life Safety POC (1/28/2020):

Compliance Date: (2/21/2020)

b>REQUESTS A DESK REVIEW

IN LIEU OF A POST SURVEY

REVISIT on or after 2/21/2020.

K 0000

Bldg. 01

A Life Safety Code Recertification and State

Licensure Survey was conducted by the Indiana

State Department of Health in accordance with 42

CFR 483.90(a).

Survey Date: 01/28/20

Facility Number: 0011149

Provider Number: 155757

AIM Number: 200829340

At this Life Safety Code survey, Rosegate Village

was found not in compliance with Requirements

K 0000 RGV Life Safety POC (1/28/2020):

Compliance Date: (2/21/2020)

b>REQUESTS A DESK REVIEW

IN LIEU OF A POST SURVEY

REVISIT on or after 2/21/2020.

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 determin

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

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 disclo

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: 4KOL21 Facility ID: 011149

TITLE

If continuation sheet of 32

(X6) DATE




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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

for Participation in Medicare/Medicaid, 42 CFR

Subpart 483.90(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 one story facility was determined to be of

Type V (111) construction and fully sprinklered.

The facility has a fire alarm system with smoke

detection in the corridors, spaces open to the

corridors, and hard wired detectors in all resident

sleeping rooms. The facility has a capacity of 150

and had a census of 138 at the time of this visit.

All areas where residents have customary access

were sprinklered and all areas providing facility

services were sprinklered.

Quality Review completed on 02/04/20

NFPA 101

Means of Egress - General

Means of Egress - General

Aisles, passageways, corridors, exit

discharges, exit locations, and accesses are

in accordance with Chapter 7, and the means

of egress is continuously maintained free of

all obstructions to full use in case of

emergency, unless modified by 18/19.2.2

through 18/19.2.11.

18.2.1, 19.2.1, 7.1.10.1

K 0211

SS=E

Bldg. 01

Based on observation and interview, the facility

failed to ensure 1 of 6 exit corridors was

continuously maintained free of obstructions.

This deficient practice could affect at least

fourteen residents on 500 hall, staff and visitors

who may use the Service hall to exit the facility.

Findings include:

K 0211 K211-Means of Egress

Means of Egress - General Aisles,

passageways, corridors, exit

discharges, exit locations, and

accesses are in accordance with

Chapter 7, and the means of

egress is continuously maintained

free of all obstructions to full use

02/21/2020 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet of 32




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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

Based on observation on 01/28/20 at 1:46 p.m.

with the Administrator and Maintenance

Supervisor (MS), the Service hall exit corridor was

used to store two utility carts, six wheelchairs,

eleven boxes and a floor machine. This would

affect the available width of the corridor used by

residents, staff and visitors who would use the

corridor to exit the facility from Service hall.

Based on interview at the time of the observation

with the Administrator, it was acknowledged the

Service hall corridor exit was not maintained free

of all obstructions.

3.1-19(b)

in case of emergency, unless

modified by 18/19.2.2 through

18/19.2.11. 18.2.1, 19.2.1,

7.1.10.1 This REQUIREMENT is

not met as evidenced by: Based

on observation and interview, the

facility failed to ensure 1 of 6 exit

corridors was continuously

maintained free of obstructions.

This deficient practice could affect

at least fourteen residents on 500

hall, staff and visitors who may

use the Service hall to exit the

facility. Based on observation on

01/28/20 at 1:46 p.m. with the

Administrator and Maintenance

Supervisor (MS), the Service hall

exit corridor was used to store two

utility carts, six wheelchairs,

eleven boxes and a floor machine.

This would affect the available

width of the corridor used by

residents, staff and visitors who

would use the corridor to exit the

facility from Service hall. Based on

interview at the time of the

observation with the Administrator,

it was acknowledged the Service

hall corridor exit was not

maintained free of all obstructions.

What corrective action(s) will

be accomplished for the

residents found to be affected

by the deficient practice?

· On 1/29/2020, all items

removed from exit corridor.

How will you identify other

residents that have the

potential to be affected by the

same deficient practice and





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7510 ROSEGATE DR

01

what corrective action will be

taken?

· All residents have the

potential to be affected.

What measures will be put into

place or what systemic

changes you will make to

ensure that the deficient

practice does not recur?

· Daily rounding of exit

corridors will be conducted by

Maintenance Director/designee.

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?

· The Maintenance

Director/designee will utilize the

CQI audit tool titled Exit Corridor

Validation-daily Monday through

Friday for 2 weeks, weekly x4

weeks, monthly x3 months and

quarterly thereafter for one year

with results reported to the Quality

Assurance and Performance

Improvement Committee overseen

by the Executive Director. If a

threshold for 90% is not achieved

an action plan will be developed to

ensure compliance.

Effective date of completion of

POC: 2/21/2020.

NFPA 101

Hazardous Areas - Enclosure


Hazardous areas are protected by a fire

barrier having 1-hour fire resistance rating

K 0321

SS=E

Bldg. 01





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01

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

automatic fire extinguishing system in

accordance with 8.7.1 or 19.3.5.9. 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, 19.3.5.9

Area Automatic Sprinkler

Separation 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 K322)


failed to ensure 2 of 2 hazardous areas observed

such as Storage rooms over 100 square feet,

would latch in their frame and be provided with a

self-closing device. This deficient practice could

affect 14 residents, staff and visitors on

Intermediate hall and Laundry.

Findings include:

K 0321 K321-Hazardous

Areas-Enclosure


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 or 19.3.5.9.

When the approved automatic fire

02/21/2020 12:00:00AM





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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

Based on observation on 01/28/20 during a tour of

the facility between 11:47 a.m. to 3:30 p.m. with the

Maintenance Supervisor (MS), there were twenty

one cardboard boxes stored in the Restorative

dining room on Intermediate hall and there was

no self closing device on the corridor door. In

addition, the door to the Laundry room which

used gas fueled dryers would not self-close and

latch into its frame. Based on interview at the time

of observation with the MS it was acknowledged

the corridor doors to the Restorative dining room

and Laundry protecting hazardous areas from an

escape route corridor was either not provided with

a self closing device or the corridor door would

not self-close and latch without manual

assistance. It was further acknowledged both

areas were over 100 square feet.

3.1-19(b)

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, 19.3.5.9 Separation 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 K322)

This REQUIREMENT is not met

as evidenced by: Based on

observation and interview, the

facility failed to ensure 2 of 2

hazardous areas observed such

as Storage rooms over 100 square

feet, would latch in their frame and

be provided with a self-closing

device. This deficient practice

could affect 14 residents, staff and

visitors on Intermediate hall and

Laundry.








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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01


· On 2/11/2020, a self-closure

unit was installed on the

restorative dining room door.

· Replacement of self-closure

springs on laundry room door

completed on 2/11/2020.






taken?








· Weekly rounding of

self-closure doors will be

conducted by Maintenance

Director/designee.






into place?

· The Maintenance


CQI audit tool titled Self-Closure

Door Validation-daily Monday

through Friday for 2 weeks,

weekly x4 weeks, monthly x3

months and quarterly thereafter for

one year with results reported to

the Quality Assurance and

Performance Improvement





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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

Committee overseen by the

Executive Director. If a threshold

for 90% is not achieved an action

plan will be developed to ensure

compliance.


POC: 2/21/2020.

NFPA 101

Fire Alarm System - Installation

Fire Alarm System - Installation

A fire alarm system is installed with systems

and components approved for the purpose in

accordance with NFPA 70, National Electric

Code, and NFPA 72, National Fire Alarm

Code to provide effective warning of fire in any

part of the building. In areas not continuously

occupied, detection is installed at each fire

alarm control unit. In new occupancy,

detection is also installed at notification

appliance circuit power extenders, and

supervising station transmitting equipment.

Fire alarm system wiring or other

transmission paths are monitored for

integrity.

18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

K 0341

SS=F

Bldg. 01


failed to ensure 1 of 1 fire alarm systems was

installed in accordance with 19.3.4.1. NFPA 72,

17.7.4.1 requires in spaces served by air handling

systems, detectors shall not be located where air

flow prevents operation of the detectors.

A.17.7.4.1 states detectors should not be located

in a direct airflow or closer than 36 inches from an

air supply diffuser or return air opening. This

deficient practice could affect all residents, staff

and visitors.

Findings include:

K 0341 K341-Fire Alarm System

Instillation

Fire Alarm System - Installation A

fire alarm system is installed with

systems and components

approved for the purpose in

accordance with NFPA 70,

National Electric Code, and NFPA

72, National Fire Alarm Code to

provide effective warning of fire in

any part of the building. In areas

not continuously occupied,

detection is installed at each fire

alarm control unit. In new

02/21/2020 12:00:00AM





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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

Based on observation on 01/28/20 at 1:49 p.m.,

with the Maintenance Supervisor (MS) the Fire

Alarm Control Panel located in the closet of the

Director of Nurse's office on 400 hall was

protected by a smoke detector, however, it was

within twelve inches from a return air vent. Based

on interview at the time of record review, the MS

acknowledged the smoke detector was within

twelve inches from a return air vent, but was

unaware it could affect the efficiency of the smoke

detector.

3.1-19(b)

occupancy, detection is also

installed at notification appliance

circuit power extenders, and

supervising station transmitting

equipment. Fire alarm system

wiring or other transmission paths

are monitored for integrity.

18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8




facility failed to ensure 1 of 1 fire

alarm systems was installed in

accordance with 19.3.4.1. NFPA

72, 17.7.4.1 requires in spaces

served by air handling systems,

detectors shall not be located

where air flow prevents operation

of the detectors. A.17.7.4.1 states

detectors should not be located in

a direct airflow or closer than 36

inches from an air supply diffuser

or return air opening. This deficient

practice could affect all residents,

staff and visitors. Based on

observation on 01/28/20 at 1:49

p.m., with the Maintenance

Supervisor (MS) the Fire Alarm

Control Panel located in the closet

of the Director of Nurse's office on

400 hall was protected by a

smoke detector, however, it was

within twelve inches from a return

air vent. Based on interview at the

time of record review, the MS

acknowledged the smoke detector

was within twelve inches from a

return air vent, but was unaware it

could affect the efficiency of the

smoke detector.





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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01





· Smoke detector in Director

of Nursing’s office was relocated

to be more then 36 inches from air

intake valve on 2/10/2020.






taken?








· Audit of smoke detectors

completed to ensure no other

detectors were less the 36 inches

from an air intake valve with no

others found to be under 36

inches.






into place?

· QAPI tool unnecessary due

to item permanently replaced.


POC: 2/21/2020.

NFPA 101

Sprinkler System - Installation

K 0351

SS=E





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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

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,

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

Bldg. 01


failed to ensure 1 of 1 complete automatic

sprinkler system was installed in accordance with

NFPA 13, 2010 Edition, Standard for the

Installation of Sprinkler Systems, to provide

complete coverage for all portions of the building.

NFPA 13, Section 8.6.3.4, "Minimum Distance

between Sprinklers", states sprinklers shall be

spaced not less than 6 feet on center. In addition,

LSC 4.6.7.5 requires existing life safety features

that do not meet the requirements for new

buildings, but exceed the requirements for existing

buildings shall not be further diminished. This

deficient practice could affect 12 residents on

Memory care including visitors and staff.

Findings include:

K 0351 K351-Sprinkle System

Instillation

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

02/21/2020 12:00:00AM





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7510 ROSEGATE DR

01


with the Maintenance Supervisor (MS), inside the

Nurse's station in Memory care there was two

sprinkler heads installed two feet apart. Based on

interview at the time of the observations, the MS

acknowledged the distance of the sprinkler heads

were spaced less than six feet on center from each

other.

3.1-19(b)

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,

19.3.5.5, 19.4.2, 19.3.5.10, 9.7,

9.7.1.1(1) This REQUIREMENT is




complete automatic sprinkler

system was installed in

accordance with NFPA 13, 2010

Edition, Standard for the

Installation of Sprinkler Systems,

to provide complete coverage for

all portions of the building. NFPA

13, Section 8.6.3.4, "Minimum

Distance between Sprinklers",

states sprinklers shall be spaced

not less than 6 feet on center. In

addition, LSC 4.6.7.5 requires

existing life safety features that do

not meet the requirements for new

buildings, but exceed the

requirements for existing buildings

shall not be further diminished.

This deficient practice could affect

12 residents on Memory care

including visitors and staff.

Findings include: Based on

observation on 01/28/20 at 2:10

p.m. with the Maintenance

Supervisor (MS), inside the

Nurse's station in Memory care

there was two sprinkler heads

installed two feet apart. Based on

interview at the time of the

observations, the MS





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acknowledged the distance of the

sprinkler heads were spaced less

than six feet on center from each

other.





· On 2/1/2020, one of the 2

sprinkler heads were removed from

Memory Care nurses station by

Integrated Fire Protection to

correct the deficient practice.






taken?

· Could have affected 12

residents on the memory care

unit.






· Audit completed on sprinkler

heads to ensure they are all at

least 6 feet apart with no

discrepancies found.






into place?

· QAPI tool not required as

this was a permanent fix of

structure.





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01


POC: 2/21/2020.

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


failed to ensure 2 of 8 smoke barriers observed

had a minimum of a 1/2 hour fire resistive rating

and the penetrations caused by the passage of

wire and/or conduit the 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 22 residents, visitors and staff.

Findings include:

Based on observations on 01/28/20 during the

tour between 2:30 p.m. to 2:55 p.m. with the

Maintenance Supervisor (MS), the smoke barrier

wall on 100 hall had a four inch by one half inch

slit through which a blue wire entered through the

smokewall and it was not firestopped.

K 0372 K372-Subdivision of Building

Spaces-Smoke Barrier

Construction

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. This

REQUIREMENT is not met as

evidenced by: Based on


02/21/2020 12:00:00AM





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

Furthermore, the smoke barrier wall on 200 hall

had a quarter size hole through which two blue

wires entered through the smokewall and it was

not firestopped. Based on interview after physical

observations by the MS it was confirmed 100 and

200 hall smokewalls had penetrations through the

walls which were not firestopped.

3.1-19(b)


smoke barriers observed had a

minimum of a 1/2 hour fire

resistive rating and the

penetrations caused by the

passage of wire and/or conduit the

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 22

residents, visitors and staff.





· On 1/28/2020, fire caulking

was completed on the 100/200

hall smoke/fire wall.






taken?

· Could have affected 22

residents.






· Audit completed on

remaining fire/smoke walls with

nothing else identified.






02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01





into place?

· Monthly preventative

maintenance inspections to be

completed to ensure there are no

penetrations through the

smoke/fire walls by the

Maintenance Director/designee.


POC: 2/21/2020.

NFPA 101

Utilities - Gas and Electric


Equipment using gas or related gas piping

complies with NFPA 54, National Fuel Gas

Code, electrical wiring and equipment

complies with NFPA 70, National Electric

Code. Existing installations can continue in

service provided no hazard to life.

18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

K 0511

SS=E

Bldg. 01


failed to ensure 3 of 3 wet locations observed

were provided with ground fault circuit interrupter

(GFCI) protection against electric shock. LSC

19.5.1.1 requires utilities comply with Section 9.1.

LSC 9.1.2 requires electrical wiring and equipment

to comply with NFPA 70, National Electrical Code.

NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault

Circuit-Interrupter Protection for Personnel,

states, ground-fault circuit-interruption for

personnel shall be provided as required in

210.8(A) through (C). The ground-fault

circuit-interrupter shall be installed in a readily

accessible location.

(B) Other Than Dwelling Units. All 125-volt,

single-phase, 15- and 20-ampere receptacles

K 0511 K511-Utilities Gas and Electric


Equipment using gas or related

gas piping complies with NFPA

54, National Fuel Gas Code,

electrical wiring and equipment

complies with NFPA 70, National

Electric Code. Existing

installations can continue in

service provided no hazard to life.

18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2.


as evidenced by: K 511 Based on


facility failed to ensure 3 of 3 wet

locations observed were provided

02/21/2020 12:00:00AM





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

installed in the locations specified in 210.8(B)(1)

through (8) shall have ground-fault

circuit-interrupter protection for personnel.

(1) Bathrooms

(2) Kitchens

(3) Rooftops

(4) Outdoors

Exception No. 1 to (3) and (4): Receptacles that are

not readily accessible and are supplied by a

branch circuit dedicated to electric snow-melting,

deicing, or pipeline and vessel heating equipment

shall be permitted to be installed in accordance

with 426.28 or 427.22, as applicable.

Exception No. 2 to (4): In industrial establishments

only, where the conditions of maintenance and

supervision ensure that only qualified personnel

are involved, an assured equipment grounding

conductor program as specified in 590.6(B)(2)

shall be permitted for only those receptacle

outlets used to supply equipment that would

create a greater hazard if power is interrupted or

having a design that is not compatible with GFCI

protection.

(5) Sinks - where receptacles are installed within

1.8 m (6 ft.) of the outside edge of the sink.

Exception No. 1 to (5): In industrial laboratories,

receptacles used to supply equipment where

removal of power would introduce a greater

hazard shall be permitted to be installed without

GFCI protection.

Exception No. 2 to (5): For receptacles located in

patient bed locations of general care or critical

care areas of health care facilities other than those

covered under

210.8(B)(1), GFCI protection shall not be required.

(6) Indoor wet locations

(7) Locker rooms with associated showering

facilities

(8) Garages, service bays, and similar areas where

electrical diagnostic equipment, electrical hand

with ground fault circuit interrupter

(GFCI) protection against electric

shock. LSC 19.5.1.1 requires

utilities comply with Section 9.1.

LSC 9.1.2 requires electrical

wiring and equipment to comply

with NFPA 70, National Electrical

Code. NFPA 70, NEC 2011

Edition at 210.8 Ground-Fault

Circuit-Interrupter Protection for

Personnel, states, ground-fault

circuit-interruption for personnel

shall be provided as required in

210.8(A) through (C). The

ground-fault circuit-interrupter shall

be installed in a readily accessible

location. (B) Other Than Dwelling

Units. All 125-volt, single-phase,

15- and 20-ampere receptacles

installed in the locations specified

in 210.8(B)(1) through (8) shall

have ground-fault circuit-interrupter

protection for personnel. (1)

Bathrooms (2) Kitchens (3)

Rooftops (4) Outdoors Exception

No. 1 to (3) and (4): Receptacles

that are not readily accessible and

are supplied by a branch circuit

dedicated to electric

snow-melting, deicing, or pipeline

and vessel heating equipment

shall be permitted to be installed

in accordance with 426.28 or

427.22, as applicable. Exception

No. 2 to (4): In industrial

establishments only, where the

conditions of maintenance and

supervision ensure that only

qualified personnel are involved, an

assured equipment grounding





02/25/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

tools.

NFPA 70, 517-20 Wet Locations, requires all

receptacles and fixed equipment within the area of

the wet location to have ground-fault circuit

interrupter (GFCI) protection. Note: Moisture can

reduce the contact resistance of the body, and

electrical insulation is more subject to failure.

This deficient practice could affect residents in

the Dining room, staff and visitors.

Findings include:


tour between at 1:14 p.m. to 1:58 p.m. with the

Administrator and Maintenance Supervisor (MS),

there were three GFCI outlets within three feet of

small sinks in the the following locations.

1. In the Breakroom on Service hall the GFCI did

not trip when tested.

2. In the Kitchen next to the rolling metal door the

GFCI had no power.

3. In the Dining room next to a small sink the GFCI

showed an "open ground" and would not trip

when tested. This was confirmed by the MS at

the time of the observations.

3.1-19(b)

conductor program as specified in

590.6(B)(2) shall be permitted for

only those receptacle outlets used

to supply equipment that would

create a greater hazard if power is

interrupted or having a design that

is not compatible with GFCI

protection. (5) Sinks - where

receptacles are installed within 1.8

m (6 ft.) of the outside edge of the

sink. Exception No. 1 to (5): In

industrial laboratories, receptacles

used to supply equipment where

removal of power would introduce

a greater hazard shall be

permitted to be installed without

GFCI protection. Exception No. 2

to (5): For receptacles located in

patient bed locations of general

care or critical care areas of health

care facilities other than those

covered under 210.8(B)(1), GFCI

protection shall not be required.

(6) Indoor wet locations (7) Locker

rooms with associated showering

facilities (8) Garages, service

bays, and similar areas where

electrical diagnostic equipment,

electrical hand tools NFPA 70,

517-20 Wet Locations, requires all

receptacles and fixed equipment

within the area of the wet location

to have ground-fault circuit

interrupter (GFCI) protection. Note:

Moisture can reduce the contact

resistance of the body, and

electrical insulation is more

subject to failure. This deficient

practice could affect residents in

the Dining room, staff and visitors.





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01





· On 2/11/2020, 3/3 GFCI

outlets were repaired to meet

standard function.






taken?

· All residents that utilize

dining room/breakroom have the







· Audit to be completed on

remaining GFCI outlets by

2/20/2020 by Maintenance

Director/designee.






into place?

· The Maintenance


CQI audit tool titled GFCI

Validation-once throughout the

facility x 1, then annually. With

results reported to the Quality








02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01



ensure compliance.


POC: 2/21/2020.

NFPA 101

HVAC - Any Heating Device

HVAC - Any Heating Device

Any heating device, other than a central

heating plant, is designed and installed so

combustible materials cannot be ignited by

device, and has a safety feature to stop fuel

and shut down equipment if there is

excessive temperature or ignition failure. If

fuel fired, the device also:

* is chimney or vent connected.

* takes air for combustion from outside.

* provides for a combustion system separate

from occupied area atmosphere.

19.5.2.2

K 0522

SS=E

Bldg. 01


failed to ensure 1 of 1 Laundry rooms on Service

hall was provided with intake combustion air from

the outside for rooms containing fuel fired

equipment. This deficient practice could create an

atmosphere rich with carbon monoxide which

could cause physical problems for staff.

Findings include:


with the Maintenance Supervisor (MS), the

Laundry room on Service hall had an automatic

louver system designed to open while the gas

dryers were operating to provide combustion air

from the outside, but the louvers remained closed.

Based on interview, it was acknowledged by the

MS the automatic louver system was not working

and he was unaware this condition existed.

K 0522 K522-HVAC-Any Heating Device

HVAC - Any Heating Device Any

heating device, other than a

central heating plant, is designed

and installed so combustible

materials cannot be ignited by

device, and has a safety feature to

stop fuel and shut down

equipment if there is excessive

temperature or ignition failure. If

fuel fired, the device also: * is

chimney or vent connected. *

takes air for combustion from

outside. * provides for a

combustion system separate from

occupied area atmosphere.

19.5.2.2 This REQUIREMENT is



02/21/2020 12:00:00AM





02/25/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

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(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

3.1-19(b)


Laundry rooms on Service hall

was provided with intake

combustion air from the outside for

rooms containing fuel fired

equipment. This deficient practice

could create an atmosphere rich

with carbon monoxide which could

cause physical problems for staff.





· On 2/10/2020, automatic

louver system was repaired to

operational status.






taken?








· Monthly rounding of

automatic louver system will be


Director/designee.






into place?

· The Maintenance





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

Director/designee to complete

preventative maintenance

rounds/service to automatic louver

system monthly and as needed.


POC: 2/21/2020.

NFPA 101

Smoking Regulations

Smoking Regulations

Smoking regulations shall be adopted and

shall include not less than the following

provisions:

(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

K 0741

SS=E

Bldg. 01

Based on observation and interview, the facility K 0741 K741-Smoking Regulations 02/21/2020 12:00:00AM





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

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(X4) ID

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TAG



DEFICIENCY)

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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

failed to properly dispose of cigarette butts for 1

of 1 outdoor areas. This deficient practice could

affect only staff.

Findings include:


with the Maintenance Supervisor (MS), there were

two cigarette butts deposited in a large plastic

trash container which also contained plastic and

paper goods outside Service hall where smoking

by staff is allowed. Based on interview

concurrent with the observation the MS stated

this was not correct procedure for the smoking

area and did not understand why staff would

deposit butts in a trash container when a non

combustible approved container was available at

the site.

3.1-19(b)

Smoking Regulations Smoking

regulations shall be adopted and

shall include not less than the

following provisions: (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 This REQUIREMENT is not

met as evidenced by: Based on


facility failed to properly dispose of

cigarette butts for 1 of 1 outdoor

areas. This deficient practice





02/25/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

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DEFICIENCY)

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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

could affect only staff.





· On 1/28/2020, trash

receptacle removed from area.






taken?

· Only staff have the potential

to be affected.






· Daily rounding of outdoor

area to be conducted by

Maintenance Director/designee to

ensure trash receptacles are not

in outdoor area.






into place?

· The Maintenance


CQI audit tool titled Outdoor Trash

Validation-weekly x4 weeks,

monthly x3 months and quarterly

thereafter for one year with results

reported to the Quality Assurance

and Performance Improvement






02/25/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

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DEFICIENCY)

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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01




compliance.


POC: 2/21/2020.

NFPA 101

Electrical Systems - Other

Electrical Systems - Other

List in the REMARKS section any NFPA 99

Chapter 6 Electrical Systems requirements

that are not addressed by the provided

K-Tags, but are deficient. This information,

along with the applicable Life Safety Code or

NFPA standard citation, should be included

on Form CMS-2567.

Chapter 6 (NFPA 99)

K 0911

SS=E

Bldg. 01


failed to ensure access and working space was

maintained in enclosures housing electrical

apparatus in 1 of 2 electrical rooms. NFPA 99,

Health Care Facilities Code, 2012 Edition, Section

6.3.2.1 states electrical installation shall be in

accordance with NFPA 70, National Electric Code.

NFPA 70, 2011 Edition, Article 110.26 states

working space for equipment operating at 600

volts, nominal, or less and likely to require

examination, adjustment, servicing, or

maintenance while energized shall comply with the

dimensions of 110.26(A)(1), (2) and (3). Distances

shall be measured from the live parts if such parts

are exposed or from the enclosure front or

opening if such are enclosed. Article 110.26(B)

states the working space required by this section

shall not be used for storage. This deficient

practice could affect at least two staff.

Findings include:

K 0911 K911-Electrical Systems-Other

Electrical Systems - Other List in

the REMARKS section any NFPA

99 Chapter 6 Electrical Systems

requirements that are not

addressed by the provided K-Tags,

but are deficient. This information,

along with the applicable Life

Safety Code or NFPA standard

citation, should be included on

Form CMS-2567. Chapter 6

(NFPA 99) This REQUIREMENT

is not met as evidenced by: Based


facility failed to ensure access and

working space was maintained in

enclosures housing electrical

apparatus in 1 of 2 electrical

rooms. NFPA 99, Health Care

Facilities Code, 2012 Edition,

Section 6.3.2.1 states electrical

installation shall be in accordance

02/21/2020 12:00:00AM





02/25/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

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TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01


with the Administrator and Maintenance

Supervisor (MS), the Electric room located in the

Riser room on Service hall had twelve footboards

stored next to the high voltage electrical panels.

Based on interview at the time of the observation,

the MS acknowledged the stored items were

present and were removed at the time of

observation.

3.1-19(b)

with NFPA 70, National Electric

Code. NFPA 70, 2011 Edition,

Article 110.26 states working

space for equipment operating at

600 volts, nominal, or less and

likely to require examination,

adjustment, servicing, or

maintenance while energized shall

comply with the dimensions of

110.26(A)(1), (2) and (3).

Distances shall be measured from

the live parts if such parts are

exposed or from the enclosure

front or opening if such are

enclosed. Article 110.26(B) states

the working space required by this

section shall not be used for

storage. This deficient practice

could affect at least two staff.





· On 1/28/2020, 12 footboards

removed from the working space of

the high voltage electrical panels.






taken?

· Only staff have the potential

to be affected.






· Daily rounding of high voltage





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

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DEFICIENCY)

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COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

electrical panel areas to be


Director/designee to ensure area

free pf clutter.

· Bright colored caution tape

to be placed on floor around

electrical panels as a visual

reminder to keep area free of

clutter.






into place?

· The Maintenance


CQI audit tool titled High Voltage

Panel Validation-weekly x4

weeks, monthly x3 months and

quarterly thereafter for one year

with results reported to the Quality






ensure compliance.


POC: 2/21/2020.

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

K 0920

SS=E

Bldg. 01





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OMB NO. 0938-039




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155757 01/28/2020

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7510 ROSEGATE DR

01

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


failed to ensure proper use of power strips in 2 of

2 areas observed. This deficient practice could

affect at least 1 to 7 residents, including visitors

and staff.

Findings include:


tour between 1:00 p.m. to 2:02 p.m. with the

Maintenance Supervisor (MS), power strips were

misused in the following areas and were not UL

listed 1363A or 60601-1:

a. A power strip was used to power an electrical

device within five feet from the resident's bed in

room # 515.

b. A power strip was used in Therapy to power

electrical equipment in a patient care area.

Based on interview concurrent with the

observations with the MS, the misuse of power

strips described in items a and b were confirmed .

K 0920 K920-Electrical

Equipment-Power Cords and

Extensions

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

02/21/2020 12:00:00AM





02/25/2020PRINTED:

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OMB NO. 0938-039




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B. WING

(X3) DATE SURVEY

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(X4) ID

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DEFICIENCY)

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155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

3.1-19(b)

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.




facility failed to ensure proper use

of power strips in 2 of 2 areas

observed. This deficient practice

could affect at least 1 to 7

residents, including visitors and

staff.





· . Power strip from room #515

power strip removed from room.

· Power strip in therapy gym

to be replaced with a UL list

1363A or 60601-1 cord by

2/21/2020.






taken?





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

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(X3) DATE SURVEY

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(X4) ID

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TAG



DEFICIENCY)

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COMPLETION



155757 01/28/2020

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7510 ROSEGATE DR

01

· 1 to 7 residents have the







· Facility audit to be

completed by Maintenance

Director/designee for use of power

strips by 2/21/2020.






into place?

· The Maintenance


CQI audit tool titled Power Strip

Validation-weekly x4 weeks,

monthly x3 months and quarterly

thereafter for one year with results

reported to the Quality Assurance

and Performance Improvement





compliance.


POC: 2/21/2020.

NFPA 101

Gas Equipment - Transfilling Cylinders

Gas Equipment - Transfilling Cylinders

Transfilling of oxygen from one cylinder to

another is in accordance with CGA P-2.5,

Transfilling of High Pressure Gaseous

Oxygen Used for Respiration. Transfilling of

K 0927

SS=E

Bldg. 01





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

any gas from one cylinder to another is

prohibited in patient care rooms. Transfilling

to liquid oxygen containers or to portable

containers over 50 psi comply with conditions

under 11.5.2.3.1 (NFPA 99). Transfilling to

liquid oxygen containers or to portable

containers under 50 psi comply with

conditions under 11.5.2.3.2 (NFPA 99).

11.5.2.2 (NFPA 99)


failed to ensure 1 of 1 oxygen transfilling rooms

was mechanically ventilated. NFPA 99 2012

edition, 11.5.2.3.1 (2) requires oxygen transfilling

rooms to be mechanically ventilated, is

sprinklered, and have ceramic or concrete flooring.

This deficient practice could affect 12 residents,

visitors or staff on 500 hall.

Findings include:


with the Maintenance Supervisor (MS), the

Oxygen storage room on 500 hall, where oxygen

transfilling occurred was provided with a direct

vent to the outside, but it was not equipped with

an electric mechanically ventilated device. Based

on an interview at the time of observation, the MS

was unsure if there was a rooftop mechanical

vent, but the lack of one was later confirmed.

3.1-19(b)

K 0927 K927-Gas Equipment-Tranfilling

Cylinders

Gas Equipment - Transfilling

Cylinders Transfilling of oxygen

from one cylinder to another is in

accordance with CGA P-2.5,

Transfilling of High Pressure

Gaseous Oxygen Used for

Respiration. Transfilling of any gas

from one cylinder to another is

prohibited in patient care rooms.

Transfilling to liquid oxygen

containers or to portable

containers over 50 psi comply with

conditions under 11.5.2.3.1 (NFPA

99). Transfilling to liquid oxygen

containers or to portable

containers under 50 psi comply

with conditions under 11.5.2.3.2

(NFPA 99). 11.5.2.2 (NFPA 99)





oxygen transfilling rooms was

mechanically ventilated. NFPA 99

2012 edition, 11.5.2.3.1 (2)

requires oxygen transfilling rooms

to be mechanically ventilated, is

sprinklered, and have ceramic or

concrete flooring. This deficient

02/21/2020 12:00:00AM





02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155757 01/28/2020

ROSEGATE VILLAGE

7510 ROSEGATE DR

01

practice could affect 12 residents,

visitors or staff on 500 hall.





· On 2/19/2020, rooftop

mechanical vent to be installed in

oxygen filling room.






taken?

· 12 residents have the







· Placement of rooftop

mechanical vent is a permanent

correction of deficient practice.






into place?

· Placement of rooftop

mechanical vent is a permanent

correction of deficient practice.

Routine preventative maintenance

to be completed per guidelines.


POC: 2/21/2020.


PRINTED: 02/25/2020 DEPARTMENT OF HEALTH AND HUMAN ...

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