PRINTED: 05/01/2018 DEPARTMENT OF HEALTH AND ...E-039 EP Testing Requirements 1. Documentation for testing the facility’s emergency preparedness program twice within the most recent

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

05/01/2018PRINTED:

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

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46256

155245 04/05/2018

CASTLETON HEALTH CARE CENTER

7630 E 86TH ST

--

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: 04/05/18

Facility Number: 000149

Provider Number: 155245

AIM Number: 100266840

At this Emergency Preparedness survey,

Castleton Health Care Center was found in

substantial compliance with Emergency

Preparedness Requirements for Medicare and

Medicaid Participating Providers and Suppliers, 42

CFR 483.73.

The facility has 109 certified beds. At the time of

the survey, the census was 36.

Quality Review completed on 04/11/18 - DA

The requirement at 42 CFR Subpart 483.73 is NOT

MET as evidenced by:

E 0000 Preparation and execution of thisplan of correction does not

constitute admission or

agreement by the provider of the

truth of the facts alleged or the

conclusions set forth in the

Statement of Deficiencies

rendered by the reviewing

agency. The Plan of Correction is

prepared and executed solely

because it is required by the

provisions of federal and state

law. Castleton Health Care

maintains that the alleged

deficiencies do not individually or

collectively jeopardize the health

and/or the safety of its residents

nor are they of such character as

to limit the provider’s capacity to

render adequate resident

care. Furthermore, Castleton

Health Care asserts that it is in

substantial compliance with

regulations governing the

operation of long term care

facilities, and this Plan of

Correction in its entirety

constitutes this provider’s credible

allegation of compliance.

We respectfully request desk

review (paper compliance) for

compliance, if acceptable.

Should additional information

be required to complete the

request, please advise.

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: XCRJ21 Facility ID: 000149

TITLE

If continuation sheet Page 1 of 25

(X6) DATE




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E 0039

SS=C

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Based on record review and interview, the facility

failed to conduct exercises to test the emergency

plan at least annually, including unannounced

staff drills using the emergency procedures. The

LTC facility must do all of the following: (i)

participate in a full-scale exercise that is

community-based or when a community-based

exercise is not accessible, an individual,

facility-based. If the LTC facility experiences an

actual natural or man-made emergency that

requires activation of the emergency plan, the

LTC facility is exempt from engaging in a

community-based or individual, facility-based

full-scale exercise for 1 year following the onset of

the actual event; (ii) conduct an additional

exercise that may include, but is not limited to the

following: (A) a second full-scale exercise that is

community-based or individual, facility-based. (B)

a tabletop exercise that includes a group

discussion led by a facilitator, using a narrated,

clinically-relevant emergency scenario, and a set

of problem statements, directed messages, or

prepared questions designed to challenge an

emergency plan; (iii) analyze the LTC facility's

response to and maintain documentation of all

drills, tabletop exercises, and emergency events,

and revise the LTC facility's emergency plan, as

needed in accordance with 42 CFR 483.73(d)(2).

This deficient practice could affect all occupants.

Findings include:

Based on review of "Comprehensive Emergency

Management Plan" documentation with the

Environmental Services Director during record

review from 9:55 a.m. to 12:00 p.m. on 04/05/18,

documentation for testing the facility's emergency

E 0039 E-039 EP Testing Requirements

1. Documentation for testing

the facility’s emergency

preparedness program twice within

the most recent twelve-month

period was not available for review.

One man made emergency was

documented on 3/29/18 due to a

dryer fire in the laundry. A plan

has been put into place to conduct

a table top exercise on the

facility’s plan which will put the

facility in compliance with EP

Testing Requirements within the

last twelve months.

2. EP Testing Requirements

were added to the facility’s TELS

program as reminder to conduct

two of the following three

exercises on a semi-annual basis

with documentation of all drills,

tabletop exercises, and

emergency events: (i) a full-scale

exercise that is community-based

or when a community-based

exercise is not accessible, an

individual, facility based. (ii)

conduct a second full-scale

exercise that is community-based

or individual, facility-based. (iii)

conduct a tabletop exercise that

includes a group discussion led by

a facilitator, using a narrated,

clinically-relevant emergency

scenario, and a set of problem

05/05/2018 12:00:00AM

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preparedness program twice within the most

recent twelve month period was not available for

review. One man-made emergency was

documented on 03/29/18 due to a dryer fire in the

Laundry. Based on interview at the time of record

review, the Environmental Services Director stated

the facility has not conducted a community based

disaster drill or conducted a table top exercise on

the facility's plan within the most recent twelve

month period.

statements, directed messages,

or prepared questions designed to

challenge an emergency plan.

3. Findings of the exercises will

be reviewed in monthly Safety

Meetings and any concerns will be

identified and addressed.

4. Date of Compliance:

05/05/18

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: 04/05/18

Facility Number: 000149

Provider Number: 155245

AIM Number: 100266840

At this Life Safety Code survey, Castleton Health

Care Center was found not in compliance with

Requirements 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 and in all areas open to

the corridor. The facility has battery operated

smoke detectors in all resident sleeping rooms.

K 0000 Preparation and execution of thisplan of correction does not

constitute admission or

agreement by the provider of the

truth of the facts alleged or the

conclusions set forth in the

Statement of Deficiencies

rendered by the reviewing

agency. The Plan of Correction is

prepared and executed solely

because it is required by the

provisions of federal and state

law. Castleton Health Care

maintains that the alleged

deficiencies do not individually or

collectively jeopardize the health

and/or the safety of its residents

nor are they of such character as

to limit the provider’s capacity to

render adequate resident

care. Furthermore, Castleton

Health Care asserts that it is in

substantial compliance with

regulations governing the

operation of long term care

facilities, and this Plan of





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The facility has a capacity of 109 and had a

census of 36 at the time of this visit.

All areas where the residents have customary

access were sprinklered and all areas providing

facility services were sprinklered.

Quality Review completed on 04/11/18 - DA

Correction in its entirety

constitutes this provider’s credible

allegation of compliance.

We respectfully request desk

review (paper compliance) for

compliance, if acceptable.

Should additional information

be required to complete the

request, please advise.

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 2 of 9 means of egress were

continuously maintained free of all obstructions

or impediments to full instant use in the case of

fire or other emergency. This deficient practice

could affect over 20 residents, staff and visitors if

needing to exit the facility.

Findings include:

Based on observations with the Environmental

Services Director and the Maintenance Assistant

during a tour of the facility from 12:00 p.m. to 2:00

p.m. on 04/05/18, the following was noted:

a. a three drawer chest of drawers was stored in

the corridor outside Room 202. The corridor

measured eight feet wide and the chest of drawers

projected two feet into the corridor.

K 0211

K-211 Means of Egress -

General

1. A three-drawer chest was

stored in the corridor outside

Room 202 and was removed on

04/06/18 An upholstered chair

across from the reception desk

was also removed on 04/06/18.

2. An audit was completed for

the rest of the facility, to ensure

that all corridors were free of

obstructions and full instant use in

the case of fire or other

emergency. No other obstructions

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b. an upholstered chair was stored in the corridor

outside the Social Services Office across from the

reception desk in the main entrance lobby. The

corridor measured eight feet wide by the reception

desk and the upholstered chair projected two feet

into the corridor.

Based on interview at the time of the

observations, the Environmental Services Director

agreed the aforementioned means of egress was

not maintained free of all obstructions or

impediments to full instant use in the case of fire

or other emergency.

3.1-19(b)

were identified.

3. Daily audits/ Environmental

rounds will be completed by

Maintenance Dir. or their designee

to ensure that all corridors are free

of obstructions. Any observations

of obstructions will be addressed

immediately.

4. Findings of the audits will be

reviewed in monthly Safety




05/05/18

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=E

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the Clinical or Security Locking requirements

are being met. In addition, the locks must be

electrical locks that fail safely so as to

release upon loss of power to the device; the

building is protected by a supervised

automatic sprinkler system and the locked

space is protected by a complete smoke

detection system (or is constantly monitored

at an attended location within the locked

space); and both the sprinkler and detection

systems are arranged to unlock the doors

upon activation.

18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4

DELAYED-EGRESS LOCKING

ARRANGEMENTS

Approved, listed delayed-egress locking

systems installed in accordance with

7.2.1.6.1 shall be permitted on door

assemblies serving low and ordinary hazard

contents in buildings protected throughout by

an approved, supervised automatic fire

detection system or an approved, supervised

automatic sprinkler system.

18.2.2.2.4, 19.2.2.2.4

ACCESS-CONTROLLED EGRESS

LOCKING ARRANGEMENTS

Access-Controlled Egress Door assemblies

installed in accordance with 7.2.1.6.2 shall

be permitted.

18.2.2.2.4, 19.2.2.2.4

ELEVATOR LOBBY EXIT ACCESS

LOCKING ARRANGEMENTS

Elevator lobby exit access door locking in

accordance with 7.2.1.6.3 shall be permitted

on door assemblies in buildings protected

throughout by an approved, supervised

automatic fire detection system and an

approved, supervised automatic sprinkler

system.

18.2.2.2.4, 19.2.2.2.4





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failed to ensure the means of egress through 1 of

9 exits was readily accessible for residents without

a clinical diagnosis requiring specialized security

measures. 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 unless otherwise permitted by LSC

19.2.2.2.4. Door-locking arrangements shall be

permitted in accordance with 19.2.2.2.5.2. This

deficient practice could affect over 10 residents,

staff and visitors if using the exit doors set by

Room 215.

Findings include:




p.m. on 04/05/18, the set of exit doors by Room

215 in the south wing was marked as a facility exit,

the exit door set could be opened by entering a

four digit code in a keypad on either side of the

door set but the exit code was not posted on

either side of the door set. Based on interview at

the time of the observations, the Environmental

Services Director stated the facility does not have

a dedicated wing or area for Alzheimer's residents,

the south wing is currently closed for upcoming

renovations and agreed the code was not posted

at the aforementioned exit on either side of the

door set.

3.1-19(b)

K 0222 K-222 Egress Doors

1. The set of exit doors by

Room 215 was marked as a

facility exit, the exit door set could

be opened by entering a four-digit

code in a keypad on either side of

the door, but the exit code was

not posted. The wing is currently

under construction and is

unoccupied. The exit signs at this

set of doors were removed on

04/09/18 as there are two other

exits within the required distance.


all other exit doors with keypads

to ensure that codes were posted.

No other exits with keypads were

missing the posted codes.

3. Weekly audits/

Environmental rounds will be

completed by Maintenance Dir. or

their designee to ensure that

identified doors are equipped with

posted codes. Any observations

of keypads without codes will be

addressed immediately.






05/05/18

05/05/2018 12:00:00AM

NFPA 101

Aisle, Corridor, or Ramp Width

Aisle, Corridor or Ramp Width

2012 EXISTING

The width of aisles or corridors (clear or

K 0232

SS=E

Bldg. 01





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unobstructed) serving as exit access shall be

at least 4 feet and maintained to provide the

convenient removal of nonambulatory patients

on stretchers, except as modified by

19.2.3.4, exceptions 1-5.

19.2.3.4, 19.2.3.5


failed to meet the clear width requirement for 2 of 9

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, provided that

all of the following conditions are met:

(a) the fixed furniture is securely attached to the

floor or to the wall.

(b) the fixed furniture does not reduce the clear

unobstructed corridor width to less than six feet,

except as permitted by 19.2.3.4(2).

(c) the fixed furniture is located only on one side

of the corridor.

(d) the fixed furniture is grouped such that each

grouping does not exceed an area of 50 square

feet.

(e) the fixed furniture groupings addressed in

19.2.3.4(5)(d) are separated from each other by a

distance of at least 10 feet.

(f) the fixed furniture is located so as to not

obstruct access to building service and fire

protection equipment.

(g) corridors throughout the smoke compartment

are protected by an electrically supervised

automatic smoke detection system in accordance

with 19.3.4, or the fixed furniture spaces are

arranged and located to allow direct supervision

by the facility staff from a nurse's station or similar

space.

(h) the smoke compartment is protected

throughout by an approved, supervised automatic

sprinkler system in accordance with 19.3.5.8.

This deficient practice could affect over 20

K 0232 K-232 Aisle, Corridor, or Ramp

Width

1. A three-drawer chest and an

upholstered chair that projected

two feet into the corridor were not

affixed to the floor or wall. Both

items were removed on 04/06/18.


any other furniture in the corridors

that would need affixed to the wall

or floor. No other items were

found.

3. Weekly audits/

Environmental rounds will be


their designee to ensure that

corridor width is maintained. Any

observations of obstructions in the

corridors will be addressed

immediately.






05/05/18

05/05/2018 12:00:00AM





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residents, staff and visitors if needing to exit the

facility.

Findings include:





a. a three drawer chest of drawers was stored in

the corridor outside Room 202. The corridor

measured eight feet wide and the chest of drawers

projected two feet into the corridor. The chest of

drawers was not affixed to the floor or to the wall.

b. an upholstered chair was stored in the corridor

outside the Social Services Office across from the

reception desk in the main entrance lobby. The

corridor measured eight feet wide by the reception

desk and the upholstered chair projected two feet

into the corridor. The chair was not affixed to the

floor or to the wall.



agreed furniture was stored in the corridor which

was not affixed to the floor or to the wall.

3.1-19(b)

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

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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 residents, staff and visitors.

Findings include:

Based on review of "Fire Watch" documentation

with the Environmental Services Director during

record review from 9:55 a.m. to 12:00 p.m. on

04/05/18, the fire watch plan for fire alarm system

impairment was incomplete. The plan failed to

include contacting the Indiana State Department

of Health via the ISDH Gateway link at

https://gateway.isdh.in.gov as the primary method

or by the secondary method when the ISDH

Gateway is nonoperational by completing the

Incident Reporting form and e-mailing it to

[email protected]. Based on interview at the

time of record review, the Environmental Services

Director agreed fire watch documentation for fire

alarm system impairment did not state to contact

the Indiana State Department of Health via the

ISDH Gateway link or at the e-mail address listed

above.

3.1-19(b)

K 0346

K-346 Fire Alarm System- Out

of Service

1. The fire watch plan and

policy has been updated to

include the ISDH Gateway link

contacting the ISDH via the ISDH

Gateway link at

https://gateway.isdh.in.gov as the

primary method or by the

secondary method when the ISDH

Gateway is nonoperational by

completing the Incident Reporting

form and emailing it to

[email protected].


all emergency documentation that

included the fire watch plan and

replaced with an updated fire

watch plan to include the ISDH

Gateway Link.

3. Monthly audits/ reviews will

be completed by Maintenance Dir.

or their designee to ensure that

the facility’s Emergency

Preparedness Planning &

Recourses Manuals-Fire Watch

includes the notification of the

Indiana State Department of

Health via the ISDH Gateway Link.






05/05/18

05/05/2018 12:00:00AM


https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]




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NFPA 101

Sprinkler System - Installation

Spinkler System - Installation

2012 EXISTING

Nursing homes, and hospitals where required

by construction type, are protected

throughout by an approved automatic

sprinkler system in accordance with NFPA

13, Standard for the Installation of Sprinkler

Systems.

In Type I and II construction, alternative

protection measures are permitted to be

substituted for sprinkler protection in specific

areas where state or local regulations prohibit

sprinklers.

In hospitals, sprinklers are not required in

clothes closets of patient sleeping rooms

where the area of the closet does not exceed

6 square feet and sprinkler coverage covers

the closet footprint as required by NFPA 13,

Standard for Installation of Sprinkler

Systems.

19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4,

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

K 0351

SS=D

Bldg. 01


failed to ensure a 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. This deficient practice could affect

over 2 staff and visitors in the detached

maintenance office and Laundry building.

Findings include:



K 0351 K-351 Sprinkler System -

Installation

1. Three sprinkler head

locations in the detached

maintenance office building were

each installed three feet apart from

one another. The vendor SafeCare

has removed the sprinkler heads

and reinstalled to the proper

distance of at least 6 feet apart.

This was completed on 04/19/18.


remaining sprinkler heads to

ensure proper distance apart. No

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p.m. on 04/05/18, three sprinkler head locations in

the detached maintenance office building were

each installed three feet apart from one another on

the ceiling. Based on interview at the time of the


agreed three sprinkler head locations on the

ceiling of the detached maintenance building were

each installed three feet apart from one another.

3.1-19(b)

other sprinkler heads were found

to be out of compliance.




sprinkler heads are in compliance

with the distance required for

sprinkler heads.






05/05/18

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


failed to provide a complete written policy

containing procedures to be followed for the

protection of all residents in the event the

automatic 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

K 0354 K-354 Sprinkler System – Out of

Service

1. The fire watch plan and

policy has been updated to

include the ISDH Gateway link

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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 residents, staff

and visitors.

Findings include:

Based on review of "Fire Watch" documentation

with the Environmental Services Director during

record review from 9:55 a.m. to 12:00 p.m. on

04/05/18, the fire watch plan for sprinkler system

impairment was incomplete. The plan failed to

include contacting the Indiana State Department

of Health via the ISDH Gateway link at

https://gateway.isdh.in.gov as the primary method

or by the secondary method when the ISDH

Gateway is nonoperational by completing the

Incident Reporting form and e-mailing it to

[email protected]. Based on interview at the

time of record review, the Environmental Services

Director agreed fire watch documentation for

sprinkler system impairment did not state to

contact the Indiana State Department of Health

via the ISDH Gateway link or at the e-mail address

listed.

3.1-19(b)

ISDH via the ISDH Gateway link at

https://gateway.isdh.in.gov as the

primary method or by the

secondary method when the ISDH

Gateway is nonoperational by

completing the Incident Reporting

form and emailing it to

[email protected].


all emergency documentation that

includes the fire watch plan and

replaced with an updated fire

watch plan to include the ISDH

Gateway Link.




the facility’s Emergency

Preparedness Planning &

Recourses Manuals-Fire Watch

includes the notification of the

Indiana State Department of

Health via the ISDH Gateway

Link.

Findings of the audits will be



identified and addressed

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=E

Bldg. 01


https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/https://gateway.isdh.in.gov/mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]




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failed to ensure 1 of 20 portable fire extinguishers

had pressure gauge readings in the acceptable

range. LSC 19.3.5.12 states portable fire

extinguishers shall be provided in all health care

occupancies in accordance with 9.7.4.1. LSC

9.7.4.1 states where required by the provisions of

another section of this Code, portable fire

extinguishers shall be selected, installed,

inspected, and maintained in accordance with

NFPA 10, the Standard for Portable Fire

Extinguishers. NFPA 10, 2010 Edition, Section

7.2.2(3) states the periodic monthly check shall

ensure the pressure gauge reading or indicator is

in the operable range or position. Section 7.2.3.1

states when an inspection of any rechargeable fire

extinguisher reveals a deficiency listed in 7.2.2(3),

the extinguisher shall be subjected to applicable

maintenance procedures. This deficient practice

could affect over 10 residents, staff and visitors in

the vicinity of Room 234.

Findings include:




p.m. on 04/05/18, the pressure gauge for the

portable ABC type fire extinguisher located in the

corridor outside Room 234 showed the

extinguisher was undercharged. Based on

interview at the time of the observations, the

Environmental Services Director stated the

extinguisher was recently changed out by

Koorsen Fire & Security because the previous

extinguisher outside Room 234 was used in a

dryer fire in the Laundry on 3/29/18 and agreed

the extinguisher should have been changed out

with an extinguisher in the acceptable pressure

range.

K 0355 K-355 Portable Fire

Extinguishers

1. The pressure gauge for the

portable ABC type fire

extinguisher located in the corridor

outside room 234 showed it was

undercharge, the extinguisher was

replaced with a new extinguisher

with the proper charge on 4/6/18.


the rest of the extinguishers in the

facility and no other extinguishers

were found to be compromised.




the facility’s extinguishers are

properly charged. Any

extinguishers found to be

compromised will be removed and

replaced immediately.






05/05/18

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3.1-19(b)

NFPA 101

Corridor - Doors

Corridor - Doors

Doors protecting corridor openings in other

than required enclosures of vertical openings,

exits, or hazardous areas resist the passage

of smoke and are made of 1 3/4 inch

solid-bonded core wood or other material

capable of resisting fire for at least 20

minutes. Doors in fully sprinklered smoke

compartments are only required to resist the

passage of smoke. Corridor doors and doors

to rooms containing flammable or

combustible materials have positive latching

hardware. Roller latches are prohibited by

CMS regulation. These requirements do not

apply to auxiliary spaces that do not contain

flammable or combustible material.

Clearance between bottom of door and floor

covering is not exceeding 1 inch. Powered

doors complying with 7.2.1.9 are permissible

if provided with a device capable of keeping

the door closed when a force of 5 lbf is

applied. There is no impediment to the

closing of the doors. Hold open devices that

release when the door is pushed or pulled are

permitted. Nonrated protective plates of

unlimited height are permitted. Dutch doors

meeting 19.3.6.3.6 are permitted. Door

frames shall be labeled and made of steel or

other materials in compliance with 8.3,

unless the smoke compartment is

sprinklered. Fixed fire window assemblies are

allowed per 8.3. In sprinklered compartments

there are no restrictions in area or fire

resistance of glass or frames in window

assemblies.

K 0363

SS=E

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19.3.6.3, 42 CFR Parts 403, 418, 460, 482,

483, and 485

Show in REMARKS details of doors such as

fire protection ratings, automatics closing

devices, etc.

1. Based on observation and interview, the

facility failed to ensure 2 of over 50 corridor doors

were provided with a means suitable for keeping

the door closed, had no impediment to closing,

latching and would resist the passage of smoke.

This deficient practice could affect over 20

residents, staff and visitors.

Findings include:





a. the corridor door to the Nourishment Pantry by

the Conference Room had no latching mechanism.

b. the corridor door to the Nourishment Pantry by

Medical Records was propped in the fully open

position with a large trash can.



agreed the two corridor doors each had an

impediment to closing, latching and would not

resist the passage of smoke.

3.1-19(b)

2. Based on observation and interview, the

facility failed to ensure 1 of 7 sets of corridor

doors would close to form a smoke resistant

barrier. Centers for Medicare & Medicaid

Services (CMS) requires sets of smoke barrier

doors which swing in the same direction and

equipped with an astragal to have a coordinator to

K 0363 K-363 Corridor - Doors

1. (A) The corridor door to the

Nourishment Pantry by the

Conference Room had no latching

mechanism. A new lockset was

installed on 4/6/18. (B) The

corridor door to the Nourishment

Pantry by Medical Records was

propped in the fully open position

with a trash can. The trash can

was removed on date of survey

(4/5/18) and rechecked again after

survey on 4/6/18. (C)The set of

corridor doors serving as the main

entrance to the Main Dining Room

swing in the same direction with

the north door equipped with an

astragal. The door set was not

equipped with a door closing

coordinator. A new door

coordinator was installed on

4/9/18.


all doors to ensure they had a

proper latch and that any

self-closing doors did not have any

impediments to closing or

latching. No other doors were

found to have any impediments.

Also, an audit was completed for

all corridor door sets and no other

door sets close in the same

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ensure the door which must close first always

closes first. This deficient practice could affect

over 20 residents, staff and visitors in the Main

Dining Room.

Findings include:




p.m. on 04/05/18, the set of corridor doors serving

as the main entrance to the Main Dining Room

from the center atrium each swing in the same

direction with the north door equipped with an

astragal. The door set was not equipped with a

door closing coordinator to ensure the door

equipped with an astragal closes last and forms a

smoke resistant barrier. Based on interview at the

time of observation, the Environmental Services

Director agreed the aforementioned corridor door

set was not equipped with a door closing

coordinator to ensure the door equipped with an

astragal closes last and forms a smoke resistant

barrier.

3.1-19(b)

direction, therefore no other door

coordinators are needed. Staff was

in serviced on policy/ the door

cannot be propped opened.

3. Weekly audits will be


their designee for identifying

concerns with any impediments

that will prevent doors from closing

properly. Concerns identified will

be immediately addressed.






05/05/18

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

K 0372

SS=E

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to the smoke barrier.

19.3.7.3, 8.6.7.1(1)

Describe any mechanical smoke control

system in REMARKS.


failed to ensure openings through 1 of 12 smoke

barrier walls were protected to maintain the fire

resistance rating of the smoke barrier. LSC

19.3.7.3 refers to Section 8.5. Section 8.5.6.2 states

penetrations for cables, conduits, pipes and

similar items that pass through a wall constructed

as a smoke barrier shall be protected by a system

or material capable of resisting the transfer of

smoke. Where a smoke barrier is also constructed

as a fire barrier, the penetrations shall be

protected in accordance with the requirements of

Section 8.3.5 to limit the spread of fire for a time

period equal to the fire resistance of the assembly

and Section 8.5.6. This deficient practice could

affect over 20 residents, staff and visitors in the

vicinity of the smoke barrier wall by Room 101.

Findings include:




p.m. on 04/05/18, a three foot by two foot hole was

noted in the attic smoke barrier wall above the

corridor door set by Room 101. A wood sheet

appeared to be pulled away from the hole and may

have covered the opening but it was detached

from the opening. The attic smoke barrier wall

consisted of one layer of five eighths inch thick

drywall on each side of the wood studs for the

wall. The fire resistance rating of the wood sheet

was not available for review. Based on interview

at the time of the observations, the Environmental

Services Director stated he was not aware of the

fire resistance rating of the wood sheet and

K 0372 K-372 Subdivision of Building Spaces – Smoke Barrier

1. A three foot by two-foot hole

was noted in the attic smoke

barrier wall above the corridor door

set by Room 101. The hole was

repaired on 04/19/18 with one

layer of five eighths inch thick

drywall on both sides of the studs.


the rest of the attic smoke barriers

and no others were found to be

compromised.




the facility’s attic smoke barrier

wall is intact and maintain the fire

resistance rating.






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agreed the aforementioned hole did not maintain

the fire resistance rating of the attic smoke barrier

wall.

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 expected

and 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. Where drills are conducted between

9:00 PM and 6:00 AM, a coded

announcement may be used instead of

audible alarms.

19.7.1.4 through 19.7.1.7

K 0712

SS=F

Bldg. 01


failed to document activation of the fire alarm

system for fire drills conducted between 6:00 a.m.

and 9:00 p.m. in the first quarter 2018 for 2 of 3

shifts. LSC 19.7.1.4 states fire drills in health care

occupancies shall include the transmission of the

fire alarm signal and simulation of emergency fire

conditions. When drills are conducted between

9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a

coded announcement shall be permitted to be

used instead of audible alarms. This deficient

practice could affect all residents, staff and

visitors in the facility.

Findings include:

Based on review of "Fire Drill Report" and Direct

Supply TELS "Logbook Documentation: Fire

Drills" documentation with the Environmental

K 0712 K-712 Fire Drills

1. Fire Drill sheets were

updated on 4/9/18 to include

documentation of verification of the

transmission of the fire alarm

system.


the review of the facility’s Fire Drill

Documentation Sheets to include

a section to document verification

of the transmission of the fire

alarm signal.




the facility’s Fire drill process

includes documentation of

verification of the transmission of

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Services Director during record review from 9:55

a.m. to 12:00 p.m. on 04/05/18, documentation for

the second shift fire drill conducted on 01/30/18 at

4:15 p.m. indicated the drill was conducted after

6:00 a.m. but before 9:00 p.m. and did not include

verification of the transmission of the fire alarm

signal. In addition, documentation for the first

shift fire drill conducted on 03/29/18 at 10:30 a.m.

also did not include verification of the

transmission of the fire alarm signal. Based on

interview at the time of record review, the

Environmental Services Director stated additional

fire drill documentation was not available for

review, he activated the fire alarm system during

each of the fire drills but agreed the

aforementioned fire drill documentation did not

include verification of the transmission of the fire

alarm signal.

3.1-19(b)

the fire alarm signal.






05/05/18

NFPA 101

Portable Space Heaters

Portable Space Heaters

Portable space heating devices shall be

prohibited in all health care occupancies,

except, unless used in nonsleeping staff and

employee areas where the heating elements

do not exceed 212 degrees Fahrenheit (100

degrees Celsius).

18.7.8, 19.7.8

K 0781

SS=E

Bldg. 01

Based on record review, observation and

interview; the facility failure to ensure 2 of 2

portable space heaters used in nonsleeping staff

and employee areas had heating elements which

do not exceed 212 degrees Fahrenheit (100

degrees Celsius). This deficient practice could

affect over 10 residents, staff and visitors.

Findings include:

K 0781 K – 781 Portable Space Heaters

1. A portable space heater was

located in the Social Services

office as well as the reception

desk in the main lobby. Both

space heaters were removed.

2. An audit was completed to

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Based on review of Vornado portable space heater

manufacturer's specifications with the

Environmental Services Director during record

review from 9:55 a.m. to 12:00 p.m. on 04/05/18,

heating element temperature documentation for

the Vornado portable space heater in the Social

Service's Office was not available for review.




p.m. on 04/05/18, a Vornado portable space heater

was located in the Social Service's Office. In

addition, a portable space heater was noted at the

reception desk in the main entrance lobby. Based

on interview at the time of record review and of

the observations, the Environmental Services

Director stated he was unaware of the maximum

temperature achieved by each of the two portable

space heaters and agreed documentation of the

maximum temperature achieved by the two

aforementioned portable space heaters was not

available for review.

ensure no other portable space

heaters were in the facility. No

other portable space heaters were

found. Facility’s space heater

policy was updated to include the

maximum temperature achieved

allowed is 212 degrees Fahrenheit

and that supporting documentation

on the space heater must be

available for review.




the facility’s space heater policy is

being followed. If during an audit a

space heater is found, we will

immediately ask for

documentation stating a maximum

temperature of 212 degrees

Fahrenheit and if not available the

space heater will be removed

immediately.






05/05/18

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

K 0920

SS=E

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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 2 of 2 extension cords including

power strips were not used as a substitute for

fixed wiring. LSC 19.5.1 requires utilities to

comply with Section 9.1. LSC 9.1.2 requires

electrical wiring and equipment to comply with

NFPA 70, National Electrical Code, 2011 Edition.

NFPA 70, Article 400.8 requires that, unless

specifically permitted, flexible cords and cables

shall not be used as a substitute for fixed wiring of

a structure. LSC Section 4.5.7 states any building

service equipment or safeguard provided for life

safety shall be designed, installed and approved

in accordance with all applicable NFPA standards.

NFPA 99, Standard for Health Care Facilities, 2012

edition, defines patient care areas as any portion

of a health care facility wherein patients are

intended to be examined or treated. Patient care

vicinity is defined as a space, within a location

intended for the examination and treatment of

patients, extending 6 ft (1.8 m) beyond the normal

location of the bed, chair, table, treadmill, or other

device that supports the patient during

K 0920 K-920 Electrical Equipment – Power Cords and Extension

Cords

1. (A) A cell phone charger and

a lamp were plugged into a power

strip on the floor three feet from

the resident bed in Room 103. The

UL listing of the power strip could

not be determined. The power strip

was removed from the resident

room on 4/6/18. (B) A power strip

was affixed to the wall above a

counter top four feet from the sink

in the Beauty Shop. The UL listing

of the power strip could not be

determined. The power strip was

removed from the Beauty Shop

during the facility tour on 4/5/18.


the rest of the facility rooms and

patient care areas for further

evidence of power strips being

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examination and treatment. A patient care vicinity

extends vertically to 7 ft 6 in. (2.3 m) above the

floor. NFPA 99, Section 10.4.2.3 states household

or office appliances not commonly equipped with

grounding conductors in their power cords shall

be permitted provided they are not located within

the patient care vicinity. This deficient practice

could affect over 10 residents, staff and visitors.

Findings include:





a. a cell phone charger and a lamp were plugged

into a power strip on the floor three feet from the

resident bed nearest the window in Room 103.

The UL listing of the power strip could not be

determined.

b. a power strip was affixed to the wall above a

counter top four feet from the sink in the Beauty

Shop. The UL listing of the power strip could not

be determined.



stated the Beauty Shop power strip is most likely

used for curling irons, blow dryers and other

electric hair care accessories and agreed power

strips were being used as a substitute for fixed

wiring and in the patient care vicinity in resident

Room 103.

3.1-19(b)

used and no other power strips

were found in patient care areas.




power strips are not being used in

resident rooms or other patient

care areas. If any power strips are

found in resident rooms or patient

care areas they will be removed

immediately unless the UL listing

can be verified as 1363A or

60601-1 and are located outside of

the 6 foot patient care vicinity.






05/05/18

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,

K 0927

SS=D

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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)


failed to ensure 1 of 1 oxygen storage locations

where transfilling occurs was in accordance with

NFPA 99, Health Care Facilities Code. NFPA 99,

2012 Edition, Section 11.5.2.3.1 states oxygen

transfilling locations shall include the following:

(1) A designated area separated from any portion

of a facility wherein patients are housed,

examined, or treated by a fire barrier of 1 hour fire

resistive construction.

(2) The area is mechanically vented, is sprinklered,

and has ceramic or concrete flooring.

(3) The area is posted with signs indicating that

transfilling is occurring and that smoking in the

immediate area is not permitted.

(4) The individual transfilling the container(s) has

been properly trained in the transfilling

procedures.

Section 11.5.3.2.3 states in health care facilities

where smoking is prohibited and signs are

prominently (strategically) placed at all major

entrances, secondary signs with no smoking

language shall not be required. This deficient

practice could affect over 2 staff and visitors in

the vicinity of the oxygen storage and transfilling

room in the Central Supply Room.

Findings include:

K 0927 K-927 Gas Equipment – Transfilling Cylinders

1. The entry door to the oxygen

storage and transfilling room was

not provided with signage

indicating that transfilling occurs in

the room. In addition it could not

be assured the mechanical vent

on the ceiling in the transfilling

room was operable. The

necessary signage was installed

on 4/9/18 also the mechanical

vent was replaced on 4/9/18.

2. No other transfilling occurs

within the building so no further

signage is required to be installed.




the signage is still in place and

that the mechanical vent inside

the transfilling room is operational.






05/05/18

05/05/2018 12:00:00AM





05/01/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155245 04/05/2018

CASTLETON HE

Documents

PRINTED: 05/01/2018 DEPARTMENT OF HEALTH AND ...E-039 EP Testing Requirements 1. Documentation for testing the facility’s emergency preparedness program twice within the most recent