printed: 02/25/2020 department of health and human
TRANSCRIPT
(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
PREFIX
TAG
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 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 Page 1 of 32
(X6) DATE
(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
PREFIX
TAG
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 46237
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 Page 2 of 32
(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
PREFIX
TAG
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 46237
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 3 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
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 - Enclosure
Hazardous areas are protected by a fire
barrier having 1-hour fire resistance rating
K 0321
SS=E
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 4 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
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)
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.
Findings include:
K 0321 K321-Hazardous
Areas-Enclosure
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 5 of 32
(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
PREFIX
TAG
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 46237
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.
What corrective action(s) will
be accomplished for the
residents found to be affected
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 6 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
by the deficient practice?
· 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.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
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?
· Weekly rounding of
self-closure doors 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 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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 7 of 32
(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
PREFIX
TAG
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 46237
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.
Effective date of completion of
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
Based on observation and interview, the 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.
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 8 of 32
(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
PREFIX
TAG
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 46237
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
This REQUIREMENT is not met
as evidenced by: Based on
observation and interview, the
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 9 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· Smoke detector in Director
of Nursing’s office was relocated
to be more then 36 inches from air
intake valve on 2/10/2020.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
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?
· 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.
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?
· QAPI tool unnecessary due
to item permanently replaced.
Effective date of completion of
POC: 2/21/2020.
NFPA 101
Sprinkler System - Installation
K 0351
SS=E
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 10 of 32
(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
PREFIX
TAG
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 46237
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
Based on observation and interview, the facility
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 11 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
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
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
not met as evidenced by: Based
on observation and interview, the
facility 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: 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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 12 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
acknowledged the distance of the
sprinkler heads were spaced less
than six feet on center from each
other.
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· 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.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
what corrective action will be
taken?
· Could have affected 12
residents on the memory care
unit.
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
· Audit completed on sprinkler
heads to ensure they are all at
least 6 feet apart with no
discrepancies found.
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?
· QAPI tool not required as
this was a permanent fix of
structure.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 13 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
Effective date of completion of
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
Based on observation and interview, the facility
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
observation and interview, the
02/21/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 14 of 32
(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
PREFIX
TAG
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 46237
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)
facility 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.
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· On 1/28/2020, fire caulking
was completed on the 100/200
hall smoke/fire wall.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
what corrective action will be
taken?
· Could have affected 22
residents.
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
· Audit completed on
remaining fire/smoke walls with
nothing else identified.
How the corrective action(s)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 15 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
will be monitored to ensure the
deficient practice will not
recur, i.e., what quality
assurance program will be put
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.
Effective date of completion of
POC: 2/21/2020.
NFPA 101
Utilities - Gas and Electric
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
Based on observation and interview, the facility
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
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.
This REQUIREMENT is not met
as evidenced by: K 511 Based on
observation and interview, the
facility failed to ensure 3 of 3 wet
locations observed were provided
02/21/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 16 of 32
(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
PREFIX
TAG
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 46237
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 17 of 32
(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
PREFIX
TAG
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 46237
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:
Based on observations on 01/28/20 during the
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 18 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· On 2/11/2020, 3/3 GFCI
outlets were repaired to meet
standard function.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
what corrective action will be
taken?
· All residents that utilize
dining room/breakroom 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?
· Audit to be completed on
remaining GFCI outlets by
2/20/2020 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 GFCI
Validation-once throughout the
facility x 1, then annually. With
results reported to the Quality
Assurance and Performance
Improvement Committee overseen
by the Executive Director. If a
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 19 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
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
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
Based on observation and interview, the facility
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:
Based on observation on 01/28/20 at 1:27 p.m.
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
not met as evidenced by: Based
on observation and interview, the
02/21/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 20 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
3.1-19(b)
facility 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.
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· On 2/10/2020, automatic
louver system was repaired to
operational status.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
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?
· Monthly rounding of
automatic louver system 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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 21 of 32
(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
PREFIX
TAG
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 46237
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.
Effective date of completion of
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 22 of 32
(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
PREFIX
TAG
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 46237
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:
Based on observation on 01/28/20 at 1:14 p.m.
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
observation and interview, the
facility failed to properly dispose of
cigarette butts for 1 of 1 outdoor
areas. This deficient practice
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 23 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
could affect only staff.
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· On 1/28/2020, trash
receptacle removed from area.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
what corrective action will be
taken?
· Only staff 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 outdoor
area to be conducted by
Maintenance Director/designee to
ensure trash receptacles are not
in outdoor area.
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 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
Committee overseen by the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 24 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
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
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
Based on observation and interview, the 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 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
on observation and interview, the
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 25 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
Based on observation on 01/28/20 at 1:24 p.m.
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.
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· On 1/28/2020, 12 footboards
removed from the working space of
the high voltage electrical panels.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
what corrective action will be
taken?
· Only staff 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 high voltage
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 26 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
electrical panel areas to be
conducted by Maintenance
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.
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 High Voltage
Panel Validation-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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 27 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
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
Based on observation and interview, the 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.
Findings include:
Based on observations on 01/28/20 during the
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 28 of 32
(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
PREFIX
TAG
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 46237
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.
This REQUIREMENT is not met
as evidenced by: Based on
observation and interview, the
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.
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· . 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.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
what corrective action will be
taken?
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 29 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
· 1 to 7 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?
· Facility audit to be
completed by Maintenance
Director/designee for use of power
strips by 2/21/2020.
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 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
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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 30 of 32
(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
PREFIX
TAG
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 46237
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)
Based on observation and interview, the facility
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:
Based on observation on 01/28/20 at 1:10 p.m.
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)
This REQUIREMENT is not met
as evidenced by: Based on
observation and interview, the
facility 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
02/21/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 31 of 32
(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
PREFIX
TAG
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 46237
155757 01/28/2020
ROSEGATE VILLAGE
7510 ROSEGATE DR
01
practice could affect 12 residents,
visitors or staff on 500 hall.
What corrective action(s) will
be accomplished for the
residents found to be affected
by the deficient practice?
· On 2/19/2020, rooftop
mechanical vent to be installed in
oxygen filling room.
How will you identify other
residents that have the
potential to be affected by the
same deficient practice and
what corrective action will be
taken?
· 12 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?
· Placement of rooftop
mechanical vent is a permanent
correction of deficient practice.
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?
· Placement of rooftop
mechanical vent is a permanent
correction of deficient practice.
Routine preventative maintenance
to be completed per guidelines.
Effective date of completion of
POC: 2/21/2020.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4KOL21 Facility ID: 011149 If continuation sheet Page 32 of 32