printed: 05/01/2018 department of health and ...e-039 ep testing requirements 1. documentation for...
TRANSCRIPT
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(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
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 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
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
--
E 0039
SS=C
Bldg. --
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 2 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
--
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 3 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 4 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
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
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 5 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
the Clinical or Security Locking requirements
are being met. In addition, the locks must be
electrical locks that fail safely so as to
release upon loss of power to the device; the
building is protected by a supervised
automatic sprinkler system and the locked
space is protected by a complete smoke
detection system (or is constantly monitored
at an attended location within the locked
space); and both the sprinkler and detection
systems are arranged to unlock the doors
upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING
ARRANGEMENTS
Approved, listed delayed-egress locking
systems installed in accordance with
7.2.1.6.1 shall be permitted on door
assemblies serving low and ordinary hazard
contents in buildings protected throughout by
an approved, supervised automatic fire
detection system or an approved, supervised
automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS
LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies
installed in accordance with 7.2.1.6.2 shall
be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS
LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in
accordance with 7.2.1.6.3 shall be permitted
on door assemblies in buildings protected
throughout by an approved, supervised
automatic fire detection system and an
approved, supervised automatic sprinkler
system.
18.2.2.2.4, 19.2.2.2.4
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 6 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
Based on observation and interview, the facility
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:
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 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.
2. An audit was completed for
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.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 7 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
unobstructed) serving as exit access shall be
at least 4 feet and maintained to provide the
convenient removal of nonambulatory patients
on stretchers, except as modified by
19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
Based on observation and interview, the facility
failed to meet 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.
2. An audit was completed for
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
completed by Maintenance Dir. or
their designee to ensure that
corridor width is maintained. Any
observations of obstructions in the
corridors will be addressed
immediately.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
05/05/18
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 8 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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. 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.
Based on interview at the time of the
observations, the Environmental Services Director
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
SS=C
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 9 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
Based on record review and interview, the facility
failed to provide a complete written policy for the
protection of residents indicating procedures to
be followed in the event the fire alarm system has
to be placed out of service for four hours or more
in a twenty four hour period in accordance with
LSC, Section 9.6.1.6. This deficient practice
affects all 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
2. An audit was completed for
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.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
05/05/18
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 10 of 25
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]
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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
Based on observation and interview, the facility
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:
Based on observations with the Environmental
Services Director and the Maintenance Assistant
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.
2. An audit was completed for
remaining sprinkler heads to
ensure proper distance apart. No
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 11 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
during a tour of the facility from 12:00 p.m. to 2:00
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
observations, the Environmental Services Director
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.
3. Monthly audits/ reviews will
be completed by Maintenance Dir.
or their designee to ensure that
sprinkler heads are in compliance
with the distance required for
sprinkler heads.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
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
Based on record review and interview, the facility
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
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 12 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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
2. An audit was completed for
all emergency documentation that
includes 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.
Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns 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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 13 of 25
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]
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
Based on observation and interview, the facility
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:
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 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.
2. An audit was completed for
the rest of the extinguishers in the
facility and no other extinguishers
were found to be compromised.
3. Monthly audits/ reviews will
be completed by Maintenance Dir.
or their designee to ensure that
the facility’s extinguishers are
properly charged. Any
extinguishers found to be
compromised will be removed and
replaced immediately.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
05/05/18
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 14 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 15 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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:
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. 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.
Based on interview at the time of the
observations, the Environmental Services Director
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.
2. An audit was completed for
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
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 16 of 25
-
(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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:
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 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
completed by Maintenance Dir. or
their designee for identifying
concerns with any impediments
that will prevent doors from closing
properly. Concerns identified will
be immediately addressed.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
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
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 17 of 25
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(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control
system in REMARKS.
Based on observation and interview, the facility
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:
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, 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.
2. An audit was completed for
the rest of the attic smoke barriers
and no others were found to be
compromised.
3. Monthly audits/ reviews will
be completed by Maintenance Dir.
or their designee to ensure that
the facility’s attic smoke barrier
wall is intact and maintain the fire
resistance rating.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
05/05/18
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 18 of 25
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(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
PREFIX
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SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
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INDIANAPOLIS, IN 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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
Based on record review and interview, the facility
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.
2. An audit was completed for
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.
3. Monthly audits/ reviews will
be completed by Maintenance Dir.
or their designee to ensure that
the facility’s Fire drill process
includes documentation of
verification of the transmission of
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 19 of 25
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(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
PREFIX
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(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
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IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
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(X5)
COMPLETION
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INDIANAPOLIS, IN 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
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
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 20 of 25
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(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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.
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, 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.
3. Monthly audits/ reviews will
be completed by Maintenance Dir.
or their designee to ensure that
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.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
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
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 21 of 25
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(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
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 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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 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.
2. An audit was completed for
the rest of the facility rooms and
patient care areas for further
evidence of power strips being
05/05/2018 12:00:00AM
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(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
PREFIX
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SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
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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
01
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:
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 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.
Based on interview at the time of the
observations, the Environmental Services Director
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.
3. Monthly audits/ reviews will
be completed by Maintenance Dir.
or their designee to ensure that
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.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
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
Bldg. 01
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(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
PREFIX
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SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
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(EACH CORRECTIVE ACTION SHOULD BE
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(X5)
COMPLETION
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INDIANAPOLIS, IN 46256
155245 04/05/2018
CASTLETON HEALTH CARE CENTER
7630 E 86TH ST
01
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)
Based on observation and interview, the facility
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.
3. Monthly audits/ reviews will
be completed by Maintenance Dir.
or their designee to ensure that
the signage is still in place and
that the mechanical vent inside
the transfilling room is operational.
4. Findings of the audits will be
reviewed in monthly Safety
Meetings and any concerns will be
identified and addressed.
5. Date of Compliance:
05/05/18
05/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XCRJ21 Facility ID: 000149 If continuation sheet Page 24 of 25
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(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
PREFIX
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(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
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(EACH CORRECTIVE ACTION SHOULD BE
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(X5)
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INDIANAPOLIS, IN 46256
155245 04/05/2018
CASTLETON HE