PRINTED: 09/27/2017 DEPARTMENT OF HEALTH …(X1) PROVIDER/SUPPLIER/CLIA DEPARTMENT OF HEALTH AND...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

09/27/2017PRINTED:

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

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46222

155389 08/16/2017

WESTPARK A WATERS COMMUNITY

1316 N TIBBS AVE

01

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 483.70(a).

Survey Date: 08/16/17

Facility Number: 000473

Provider Number: 155389

AIM Number: 100290410

At this Life Safety Code survey,

Westpark a Waters Community 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 one story facility consisted of two

sections: the original section determined

to be Type III (200) construction and the

Addition was determined to be Type V

(000) construction. The facility is fully

sprinklered. The facility has a fire alarm

system with smoke detection in the

corridors and in all areas open to the

K 0000 The creation and submission of this

plan of correction does not

constitute an admission by this

provider of any conclusion set forth

in the statement of deficiencies, or

any violation of regulation. Facility

would like to request paper

compliance.

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: 2Q8J21 Facility ID: 000473

TITLE

If continuation sheet of 21

(X6) DATE




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corridor. The facility has smoke

detectors hard wired to the fire alarm

system in all resident sleeping rooms.

The entire facility was surveyed as Type

V (000) construction. The facility has a

capacity of 89 and had a census of 51 at

the time of this visit.

All areas where the residents have

customary access were sprinklered. The

facility has two detached storage sheds

which were not sprinklered.

Quality Review completed on 08/24/17 -

DA

NFPA 101

Aisle, Corridor, or Ramp Width

Aisle, Corridor or Ramp Width

2012 EXISTING

The width of aisles or corridors (clear or

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

K 0232

SS=E

Bldg. 01

Based on observation and interview, the

facility failed to meet the clear width

requirement for 1 of 7 corridors or met an

exception per 19.2.3.4(5). LSC

19.2.3.4(5) states where the corridor

width is at least 8 feet, projections into

the required width shall be permitted for

fixed furniture under certain conditions.

This deficient practice could affect 15

K 0232 K232 Aisle, Corridor or Ramp Width

2012 EXISTING

It is the practice of this provider to

ensure that egress for all noted exits

have a minimum of egress of 4’per

regualtion and maintained to

provide convenient removal of

nonambulatory patients .

What corrective action will be taken

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residents, staff and visitors.

Findings include:

Based on observations with the Head of

Maintenance during a tour of the facility

from 9:15 a.m. to 11:10 p.m. on

08/16/17, the east alcove means of egress

measured ten feet wide and contained

three vending machines which were not

considered to be furniture. Two vending

machines were stored in the means of

egress on the north side of the corridor

and each vending machine projected

three feet into the ten foot wide corridor

width. A third vending machine was also

stored in the means of egress on the south

side of the corridor directly across the

north side of the corridor from a vending

machine which also projected three feet

into the ten foot wide corridor width.

The vending machines were not located

on only one side of the corridor and

reduced the clear unobstructed corridor

width to less than six feet. Based on

interview at the time of the observations,

the Head of Maintenance stated the

vending machines were recently relocated

to the east alcove and reduced the clear

unobstructed corridor width to less than

six feet.

3.1-19(b)

for the 15 residents, staff, or visitors

that could be affected by this

egress? The facility removed the

vending machine on south wall

completely creating a 7’ egress and

clear path to east exit door.

How other residents having the

potential to be affected by the same

deficient practice will be identified

and what corrective actions will be

taken? The facility will keep this

egress clear for all residents, staff, or

visitors that would need to use this

egress passage.

What measures will be put in place

or what systemic change will be

made to ensure that the deficient

practice does not occur? Complete

removal of 3rd machine on South

wall, and not to be replaced.

How the corrective action will be

monitored to ensure the deficient

practice will not occur, i.e., what

quality assurance program will be

put in place? No more than 2

vending machines will be located in

this area, and those 2 will be affixed

to the north wall. 7’ ingress/egress

will be maintained at all times and

checked monthly by maintenance

director.

This systemic change will be done by

Sept. 15, 2017.





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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,

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

K 0324

SS=D

Bldg. 01

1. Based on record review, observation

and interview; the facility failed to ensure

1 of 1 kitchen exhaust systems was

inspected in accordance with NFPA 96.

NFPA 96, 2011 Edition, Standard for

Ventilation Control and Fire Protection

of Commercial Cooking Operations,

Section 11.4 states the entire exhaust

system shall be inspected for grease

buildup by a properly trained, qualified,

and certified person(s) acceptable to the

authority having jurisdiction and in

accordance with Table 11.4. Table 11.4,

Schedule for Inspection for Grease

K 0324 K324 Cooking Facilities

It is the practice of this provider to

ensure that all inspections for

cooking facility equipment are done

bi-annually and inspection is

available to all authority that

request said document. Also, that a

drip tray will be installed for

continued use and safety on vent

hood.


for the 2 staff and visitors that could

be affected by this deficient

practice? Bi-annual inspection by

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Buildup, requires systems serving

moderate volume cooking operations

shall be inspected semiannually. Section

11.6.1 states, upon inspection, if the

exhaust system is found to be

contaminated with deposits from grease

laden vapors, the contaminated portions

of the exhaust system shall be cleaned by

a properly trained, qualified, and

certified person(s) acceptable to the

authority having jurisdiction. Hoods,

grease removal devices, fans, ducts, and

other appurtenances shall be cleaned to

remove combustible contaminants prior

to surfaces becoming heavily

contaminated with grease or oily sludge.

After the exhaust system is cleaned, it

shall not be coated with powder or other

substance. When an exhaust cleaning

service is used, a certificate showing the

name of the servicing company, the name

of the person performing the work, and

the date of inspection or cleaning shall be

maintained on the premises. This

deficient practice could affect two staff

and visitors.

Findings include:

Based on record review with the Head of

Maintenance from 11:10 a.m. to 12:50

p.m. on 08/16/17, documentation of

semiannual kitchen exhaust system

inspection for the most recent twelve

HOODZ Job Service will be done,

with sticker affixed, and inspection

recorded by maintenance director.

Also, SafeCare will create drip tray

for hood vent for possible grease

resolution.



defective practice will be identified

and what corrective actions will take

place? Kitchen staff workers can be

affected, along with visitors to this

area of facility. The inspections will

be done on time, recorded, and drip

tray for vent installed.

What measures will be put into

place or what systemic changes will

be made to ensure that the deficient

practice does not occur? HOODZ

Job Service is retained to do 2X a

year inspection of hood vent to

ensure safe, clean use of equipment,

and affix sticker at each inspection.

This inspection will be retained by

maintenance director and produced

when needed by requestors.



practice will not reoccur, i.e., what


put in place? The inspection of hood

vents and the installation of drip

tray on hood vent will be duly noted

in monthly Safety Committee

meeting in month that it takes place,

and will be reported to QAPI group

in the appropriate monthly meeting.





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month period was not available for

review. Based on interview at the time of

record review, the Head of Maintenance

stated documentation of semiannual

kitchen exhaust system inspection for the

most recent twelve month period was not

available for review. Based on

observations with the Head of


from 9:15 a.m. to 11:10 p.m. on

08/16/17, no inspection contractor had

affixed a sticker to the range hood in the

kitchen documenting kitchen exhaust

system inspections within the most recent

twelve month period.

3.1-19(b)

2. Based on observation and interview,

the facility failed to install the kitchen

range hood system in accordance with the

requirements of LSC 9.2.3. Section 9.2.3

states commercial cooking equipment

shall be installed in accordance with

NFPA 96, Standard for Ventilation

Control and Fire Protection of

Commercial Cooking Operations. NFPA

96, 2011 edition, Section 6.2.4.1 states

kitchen range hood system filters shall be

equipped with a drip tray beneath their

lower edges. The tray shall be kept to the

minimum size needed to collect grease

and shall be pitched to drain into an

enclosed metal container having a

This systemic change will be done by

Sept. 15, 2017.





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capacity not exceeding 1 gal (3.785 L).

This deficient practice could affect two

staff and visitors in the kitchen.

Findings include:



from 9:15 a.m. to 11:10 p.m. on

08/16/17, the kitchen range hood system

filters were not equipped with a pitched

drip tray and was missing an enclosed

metal container for grease to drain into.

Based on interview at the time of the

observations, the Head of Maintenance

stated the kitchen range hood system had

no designated location underneath the

kitchen range hood system for a drip tray

and was missing an enclosed metal

container for grease to drain into.

3.1-19(b)

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

Water-based Fire Protection Systems.

K 0353

SS=F

Bldg. 01





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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

1. Based on record review, observation

and interview; the facility failed to

document sprinkler system inspections in

accordance with NFPA 25. NFPA 25,

Standard for the Inspection, Testing, and

Maintenance of Water-Based Fire

Protection Systems, 2011 Edition,

Section 5.2.4.1 states gauges on wet pipe

sprinkler systems shall be inspected

monthly to ensure that they are in good

condition and that normal water supply

pressure is being maintained. Section

5.2.4.2 states gauges on dry pipe

sprinkler systems shall be inspected

weekly to ensure that normal air and

water pressures are being maintained.

Section 5.1.2 states valves and fire

department connections shall be

inspected, tested, and maintained in

accordance with Chapter 13. Section

13.1.1.2 states Table 13.1.1.2 shall be

utilized for inspection, testing and

maintenance of valves, valve components

K 0353 It is the practice of this provider to

ensure the sprinkling system and

control valves are maintained and

inspected in a safe manner .


for those residents that have been

affected by the deficient practice?

Weekly checks of wet and dry

sprinkling system will be inspected

and log kept showing that all gauges

are in working order. Also, that

escutcheon in 2 affected areas,

employee breakroom and

equipment room are replaced.

How other residents have the




taken? Maintenance director will

keep a weekly log to document that

gauges and control valves for

sprinkling system are in working

order. All residents could be affected

if gauges were not functioning

properly.



09/15/2017 12:00:00AM





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and trim. Section 4.3.1 states records

shall be made for all inspections, tests,

and maintenance of the system and its

components and shall be made available

to the authority having jurisdiction upon

request. This deficient practice could

affect all residents, staff, and visitors.

Findings include:

Based on review of SafeCare's "Report of

Inspection" documentation dated

08/29/16, 11/29/16, 02/15/17 and

05/25/17 with the Head of Maintenance

during record review from 11:10 a.m. to

12:50 p.m. on 08/16/17, weekly dry

sprinkler system gauge inspection

documentation for 48 weeks of the most

recent 52 week period was not available

for review. Monthly wet sprinkler

system gauge inspection documentation

for 8 months of the most recent 12 month

period was also not available for review.

In addition, monthly inspection

documentation for all sprinkler system

control valves for 8 months of the most

recent 12 month period was not available

for review. Based on interview at the

time of record review, the Head of

Maintenance stated the facility frequently

checks sprinkler gauges and valves but

sprinkler system gauge and control valve

inspection documentation for the

aforementioned weekly and monthly


practice does not occur?

Maintenance Director will do weekly

checks, log them, and keep log book

for availability to requestors. The 2

escutcheons will be replaced in

break room and equipment room.



practice will not occur, I.e., what


put in place? Weekly log will be

kept by Maintenance Director, who

will report monthly to safety

committee. It will be followed as a

monthly item in QAPI for him to

report. Two escutcheons will be

replaced and any others that need

repair or replacement.





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periods was not available for review.



from 9:15 a.m. to 11:10 p.m. on

08/16/17, the facility has supervised wet

and dry sprinkler systems.

3.1-19(b)


the facility failed to ensure 2 of over 100

sprinkler heads in the facility were

maintained. NFPA 13, Standard for the

Installation of Sprinkler Systems, 2010

Edition, Section 6.2.7.2 states

escutcheons used with recessed,

flush-type or concealed sprinklers shall

be part of a listed sprinkler assembly.

This deficient practice could affect 12

residents, staff and visitors in the vicinity

of the Employee Break Room.

Findings include:

Based on observations with the Director

of Environmental Services (DES) during

a tour of the facility from 9:15 a.m. to

11:10 p.m. on 08/16/17, the sprinkler

head located in the corridor by the

Employee Break Room and the sprinkler

head located in the Equipment Room

were both missing its respective

escutcheon. Based on interview at the

time of the observations, the DES agreed





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the aforementioned sprinkler locations

had a missing escutcheon plate.

3.1-19(b)

NFPA 101

Portable Fire Extinguishers

Portable Fire Extinguishers

Portable fire extinguishers are selected,

installed, inspected, and maintained in

accordance with NFPA 10, Standard for

Portable Fire Extinguishers.

18.3.5.12, 19.3.5.12, NFPA 10

K 0355

SS=D

Bldg. 01


the facility failed to ensure 1 of 15

portable fire extinguishers were readily

accessible and immediately available in

accordance with NFPA 10. NFPA 10,

Standard for Portable Fire Extinguishers,

2010 Edition, Section 6.1.3.1 states fire

extinguishers shall be readily accessible

and immediately available in the event of

a fire. Fire extinguishers shall not be

obstructed or obstructed from view. This

deficient practice could affect 2 staff and

visitors in the kitchen.

Findings include:




ensure that all fire extinguishers In

the facility are in working order,

inspected, and installed in the

correct manner.


for those residents that have been

affected by the deficient practice?

The K Class fire extinguisher in the

kitchen area will be installed in the

correct bracket and hung in an area

that is unimpeded for use. Nothing

will be stored in front of the fire

extinguisher.





taken? All kitchen staff and visitors

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from 9:15 a.m. to 11:10 p.m. on

08/16/17, a five foot tall stack of bread

trays was placed on the floor in front of

the portable K Class fire extinguisher in

the kitchen which blocked ready access

and immediate availability for the fire

extinguisher. Based on interview at the

time of the observations, the Head of

Maintenance stated the bread trays should

not have been placed in front of the fire

extinguisher and blocked it from ready

access and immediate availability.

3.1-19(b)


the facility failed to ensure 1 of 15

portable fire extinguishers were installed

in accordance with NFPA 10. NFPA 10,

Standard for Portable Fire Extinguishers,

2010 Edition, Section 6.1.3.4 states

portable fire extinguishers other than

wheeled extinguishers shall be installed

using any of the following means:

(1) Securely on a hanger intended for the

extinguisher

(2) In the bracket supplied by the

extinguisher manufacturer

(3) In a listed bracket approved for such

purpose

(4) In cabinets or wall recesses

Section 6.1.3.8.1 states fire extinguishers

having a gross weight not exceeding 40

lb shall be installed so that the top of the

to the area could be affected by fire

extinguisher not being properly

installed and hung on wall.




practice does not occur? A new

bracket is installed that is

appropriate for hanging a K Class

extinguisher. Kitchen staff has been

educated not to place anything in

front of extinguishing devices.



practice will not occur, i.e., what


put in place? The K Class fire

extinguisher has been hung in

correct bracket. Maintenance

Director will do visual inspection on

weekly basis and report to Safety

Committee and QAPI monthly

advising that all safe measures are in

place.

The systemic change will be done by

Sept. 15, 2017.





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fire extinguisher is not more than five

feet above the floor. Section 6.1.3.8.3

states in no case shall the clearance

between the bottom of the hand portable

fire extinguisher and the floor be less

than four inches. This deficient practice

could affect 2 staff and visitors in the

kitchen.

Findings include:



from 9:15 a.m. to 11:10 p.m. on

08/16/17, the portable K Class fire

extinguisher in the kitchen was

freestanding on the floor behind a five

foot tall stack of bread trays which

blocked ready access and immediate

availability for the fire extinguisher. The

designated location on the wall for the

fire extinguisher by the K Class placard

was missing its hanger or supporting

bracket. Based on interview at the time

of observation, the Head of Maintenance

stated the kitchen staff didn't tell him the

portable fire extinguisher hanger or

supporting bracket was missing and it

should not have been placed on the floor

behind the bread trays.

3.1-19(b)





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NFPA 101

Subdivision of Building Spaces - Smoke

Barrie


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 1 of 1 ceiling

smoke barriers was maintained to provide

at least a one half hour fire resistance

rating. This deficient practice could

affect all residents, staff and visitors.

Findings include:

Based on observations with the Director

of Environmental Services (DES) and the

Head of Maintenance during a tour of the

facility from 9:15 a.m. to 11:10 p.m. on

08/16/17, the following was noted:

a. a two inch hole by a sprinkler


ensure that all smoke barriers are

complete and provide at least one

half hour fire resistance rating.


for the 4 identified areas that could

be affected by this deficient

practice? Maintenance Director to

repair a two inch hole by sprinkler

escutcheon in Janitor’s Closet by the

west nurse’s station, a one half inch

hole by sprinkler escutcheon in

ceiling above the Medical Records

desk by west nurse’s station, a three

inch hole in the ceiling by the

sprinkler escutcheon in the

Progressive Wellness Therapy Center

09/15/2017 12:00:00AM





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155389 08/16/2017


1316 N TIBBS AVE

01

escutcheon in the ceiling of the Janitor's

Closet by the west nurse's station.

b. a one half inch hole by a sprinkler

escutcheon in the ceiling above the

Medical Records desk by the west nurse's

station.

c. a three inch hole by a sprinkler

escutcheon in the ceiling of the restroom

in the Progressive Wellness Therapy

Center in the west hall.

d. a two inch hole in the ceiling above the

"E1" Emergency Panel in the transfer

switch room.

Based on interview at the time of the

observations, the (DES) and the Head of

Maintenance agreed the holes in the

ceiling did not maintain the fire

resistance rating of the ceiling smoke

barrier.

3.1-19(b)

in the west hall, and a two inch hole

in the ceiling above the “E1”

Emergency Panel in the transfer

switch room.





place? This deficient practice could

affect all residents, staff, and

visitors. That is why the 4 identified

areas in the ceiling have been

sealed by Maintenance Director.


place or systemic changes will be


practice does not recur? All smoke

barriers will be sealed and evidence

of such be recorded to ensure the

safety of all residents, staff, and

visitors.



practice will not recur, i.e., what


put in place? All areas have been

sealed by Maintenance Director and

will be checked monthly prior to

Safety Committee Meeting to ensure

the integrity of the seal.

The systemic change is done, and to

be included in the Sept. 15, 2017

date.

NFPA 101 K 0374





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B. WING

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Barrie


Barrier Doors

2012 EXISTING

Doors in smoke barriers are 1-3/4-inch thick

solid bonded wood-core doors or of

construction that resists fire for 20 minutes.

Nonrated protective plates of unlimited

height are permitted. Doors are permitted to

have fixed fire window assemblies per 8.5.

Doors are self-closing or automatic-closing,

do not require latching, and are not required

to swing in the direction of egress travel.

Door opening provides a minimum clear

width of 32 inches for swinging or horizontal

doors.

19.3.7.6, 19.3.7.8, 19.3.7.9

SS=E

Bldg. 01

Based on record review, observation and

interview; the facility failed to ensure 1

of 2 rolling fire doors was maintained in

accordance with NFPA 80. LSC

19.3.7.6.2 states doors shall be permitted

to have fixed fire window assemblies in

accordance with Section 8.5. LSC

8.5.4.5 states fire window assemblies

shall comply with 8.3.3. LSC 8.3.3.1

states fire window assemblies and their

accompanying hardware, including all

frames, closing devices, anchorage and

sills shall be in accordance with the

requirements of NFPA 80, Standard for

Fire Doors and Other Openings

Protectives. NFPA 80, 2010 Edition,

Section 5.2 states fire door assemblies

shall be inspected and tested not less than

annually, and a written record of the


ensure that all inspections for rolling

fire doors in the kitchen area are

available, completed, tagged, and

current.

What corrective action will be

accomplished for those residents

found to be affected by the deficient

practice? SafeCare did a full

inspection on the rolling fire door,

tagged it, and documented it to the

Maintenance Director.





taken? The deficient practice could

affect 20 residents, staff, and visitors

in the main dining room.


09/15/2017 12:00:00AM





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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inspection shall be signed and kept for

inspection by the authority having

jurisdiction. This deficient practice could

affect 20 residents, staff and visitors in

the main dining room.

Findings include:

Based on record review with the Head of

Maintenance from 11:10 a.m. to 12:50

p.m. on 08/16/17, documentation of

annual rolling fire door inspection within

the most recent twelve month period was

not available for review. Based on

observations with the Head of


from 9:15 a.m. to 11:10 p.m. on

08/16/17, two metal horizontal rolling

fire doors were noted in the smoke

barrier wall separating the kitchen from

the main dining room. SafeCare had

affixed a maintenance tag to the rolling

fire door for the dish return/dish washing

area indicating an inspection was

performed on 02/16/17 but annual

inspection documentation within the

most recent twelve month period for the

rolling fire door at the serving window

was not affixed to the rolling fire door.

Based on interview at the time of record

review and of the observations, the Head

of Maintenance stated he had SafeCare

service the dish area rolling fire door in

February 2017 but stated documentation

or what systemic changes will be


practice does not recur? The annual

inspection by SafeCare will be

documented, tagged, and recorded

by Maintenance Director and

available for inspection.





put in place? Maintenance Director

will schedule and make sure that

rolling door inspection for barrier

are done annually, and kept in log

that is available. When completed

annually it will be reported to Safety

Committee and QAPI in the month

that it takes place.


Sept. 15, 2017.





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

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(X5)

COMPLETION



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of annual rolling fire door inspection

within the most recent twelve month

period for the serving window rolling fire

door was not available for review.

3.1-19(b)

NFPA 101

Fire Drills

Fire Drills

Fire drills include the transmission of a fire

alarm signal and simulation of emergency

fire conditions. Fire drills are held at

unexpected times under varying conditions,

at least quarterly on each shift. The staff is

familiar with procedures and is aware that

drills are part of established routine.

Responsibility for planning and conducting

drills is assigned only to competent persons

who are qualified to exercise leadership.

Where drills are conducted between 9:00

PM and 6:00 AM, a coded announcement

may be used instead of audible alarms.

18.7.1.4 through 18.7.1.7, 19.7.1.4 through

19.7.1.7

K 0712

SS=F

Bldg. 01

Based on record review and interview,

the facility failed to provide

documentation of a fire drill conducted

on the second and third shifts for 1 of 4

quarters. This deficient practice affects

all residents, staff and visitors.

Findings include:


ensure that all fire drills are done in

accordance with regulation for the

safety of all staff, residents, and

visitors in the facility.

What corrective actions will be


found to be affected by the deficient

practice? Fire Drills will be

scheduled at unexpected times on

09/15/2017 12:00:00AM





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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Based on review of "Fire Drill Report"

documentation with the Head of

Maintenance during record review from

11:10 a.m. to 12:50 p.m. on 08/16/17,

documentation of a fire drill conducted

on the second shift in the fourth quarter

(October, November, December) of 2016

and documentation of a fire drill

conducted on the third shift in the first

quarter (January, February, March) of

2017 was not available for review. Based

on interview at the time of record review,

the Head of Maintenance stated they

conduct quarterly fire drills on each shift

once per quarter but documentation for

fire drills conducted on the

aforementioned shifts and quarters was

not available for review.

3.1-19(b)

every shift at least quarterly and

documented through a signed log

book kept by Maintenance Director.





place? The deficient practice could

affect all residents, staff, and

visitors.

What measure will be put into place

or systemic changes will be made to

ensure that the deficient practice

does not recur? All quarterly fire

drills will be reported for each shift

by the Maintenance Director to the

Safety Committee and duly noted in

QAPI in the month they take place.





put in place? The Maintenance

Director will keep a log of all fire

drills for each shift, report it to the

Safety Committee in the month that

it takes place, and, also, report it to

the monthly QAPI committee at

least quarterly per the regulation.


Sept. 15, 2017.

NFPA 101

Smoking Regulations

Smoking Regulations

K 0741

SS=E

Bldg. 01





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

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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

Based on record review, observation and

interview; the facility failed to ensure

smoking materials were deposited into

ashtrays and metal containers with

self-closing cover devices into which

ashtrays can be emptied of

noncombustible material and safe design

in 1 of 1 outdoor areas where smoking is

permitted. This deficient practice could

affect five residents, staff and visitors in

the courtyard smoking area.


ensure that all smoking materials in

the smoking area are disposed of in

accordance with regulations for said

practice.

What corrective actions will be


found to have been affected by the

deficient practice? Ash trays will be

provided for smokers in the smoking

area and metal containers will be

09/15/2017 12:00:00AM





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




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DEFICIENCY)

(X5)

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155389 08/16/2017


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Findings include:

Based on record review from 11:10 a.m.

to 12:50 p.m. on 08/16/17, the Head of

Maintenance stated the facility's current

policy is assessed residents are allowed to

smoke with staff supervision in the

courtyard area. Based on observations

with the Head of Maintenance during a

tour of the facility from 9:15 a.m. to

11:10 a.m. on 08/16/17, over 50 cigarette

butts were strewn on the ground outside

the facility in the courtyard resident

smoking area. A smoking tower for

depositing smoking materials was present

at the location. Based on interview at the

time of the observations, the Head of

Maintenance stated staff are present when

residents are smoking at this outdoor

location and but stated ashtrays and metal

containers were not being used

consistently by residents at this

aforementioned location where resident

smoking was taking place.

3.1-19(b)

provided for emptying the ash trays

and readily available in this area.





place? The deficient practice could

affect five residents, staff, and

visitors in the smoking area.


place or what systemic changes will

be made to ensure that the deficient

practice does not recur? The facility

will provide ample ash trays in the

smoking area, supervision will

ensure they are used, and they will

be emptied into metal containers

provided in the smoking area.

How the corrective actions will be




put in place? The smoking area will

be maintained by supervising staff

and part of the monthly Safety

Committee with a report by

Maintenance Director. This report

will be included in QAPI meeting

monthly for 3 months or until no

more needed resolution for K741 is

needed.


Sept., 15, 2017.


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