printed: 09/27/2017 department of health …(x1) provider/supplier/clia department of health and...
TRANSCRIPT
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
K 0000
Bldg. 01
A Life Safety Code Recertification and
State Licensure Survey was conducted by
the Indiana State Department of Health in
accordance with 42 CFR 483.70(a).
Survey Date: 08/16/17
Facility Number: 000473
Provider Number: 155389
AIM Number: 100290410
At this Life Safety Code survey,
Westpark a Waters Community was
found not in compliance with
Requirements for Participation in
Medicare/Medicaid, 42 CFR Subpart
483.70(a), Life Safety from Fire and the
2012 edition of the National Fire
Protection Association (NFPA) 101, Life
Safety Code (LSC), Chapter 19, Existing
Health Care Occupancies and 410 IAC
16.2.
This one story facility consisted of two
sections: the original section determined
to be Type III (200) construction and the
Addition was determined to be Type V
(000) construction. The facility is fully
sprinklered. The facility has a fire alarm
system with smoke detection in the
corridors and in all areas open to the
K 0000 The creation and submission of this
plan of correction does not
constitute an admission by this
provider of any conclusion set forth
in the statement of deficiencies, or
any violation of regulation. Facility
would like to request paper
compliance.
FORM CMS-2567(02-99) Previous Versions Obsolete
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: 2Q8J21 Facility ID: 000473
TITLE
If continuation sheet Page 1 of 21
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
corridor. The facility has smoke
detectors hard wired to the fire alarm
system in all resident sleeping rooms.
The entire facility was surveyed as Type
V (000) construction. The facility has a
capacity of 89 and had a census of 51 at
the time of this visit.
All areas where the residents have
customary access were sprinklered. The
facility has two detached storage sheds
which were not sprinklered.
Quality Review completed on 08/24/17 -
DA
NFPA 101
Aisle, Corridor, or Ramp Width
Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or
unobstructed) serving as exit access shall
be at least 4 feet and maintained to provide
the convenient removal of nonambulatory
patients on stretchers, except as modified by
19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
K 0232
SS=E
Bldg. 01
Based on observation and interview, the
facility failed to meet the clear width
requirement for 1 of 7 corridors or met an
exception per 19.2.3.4(5). LSC
19.2.3.4(5) states where the corridor
width is at least 8 feet, projections into
the required width shall be permitted for
fixed furniture under certain conditions.
This deficient practice could affect 15
K 0232 K232 Aisle, Corridor or Ramp Width
2012 EXISTING
It is the practice of this provider to
ensure that egress for all noted exits
have a minimum of egress of 4’per
regualtion and maintained to
provide convenient removal of
nonambulatory patients .
What corrective action will be taken
09/15/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 2 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
residents, staff and visitors.
Findings include:
Based on observations with the Head of
Maintenance during a tour of the facility
from 9:15 a.m. to 11:10 p.m. on
08/16/17, the east alcove means of egress
measured ten feet wide and contained
three vending machines which were not
considered to be furniture. Two vending
machines were stored in the means of
egress on the north side of the corridor
and each vending machine projected
three feet into the ten foot wide corridor
width. A third vending machine was also
stored in the means of egress on the south
side of the corridor directly across the
north side of the corridor from a vending
machine which also projected three feet
into the ten foot wide corridor width.
The vending machines were not located
on only one side of the corridor and
reduced the clear unobstructed corridor
width to less than six feet. Based on
interview at the time of the observations,
the Head of Maintenance stated the
vending machines were recently relocated
to the east alcove and reduced the clear
unobstructed corridor width to less than
six feet.
3.1-19(b)
for the 15 residents, staff, or visitors
that could be affected by this
egress? The facility removed the
vending machine on south wall
completely creating a 7’ egress and
clear path to east exit door.
How other residents having the
potential to be affected by the same
deficient practice will be identified
and what corrective actions will be
taken? The facility will keep this
egress clear for all residents, staff, or
visitors that would need to use this
egress passage.
What measures will be put in place
or what systemic change will be
made to ensure that the deficient
practice does not occur? Complete
removal of 3rd machine on South
wall, and not to be replaced.
How the corrective action will be
monitored to ensure the deficient
practice will not occur, i.e., what
quality assurance program will be
put in place? No more than 2
vending machines will be located in
this area, and those 2 will be affixed
to the north wall. 7’ ingress/egress
will be maintained at all times and
checked monthly by maintenance
director.
This systemic change will be done by
Sept. 15, 2017.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 3 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
NFPA 101
Cooking Facilities
Cooking Facilities
Cooking equipment is protected in
accordance with NFPA 96, Standard for
Ventilation Control and Fire Protection of
Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small
appliances such as microwaves, hot plates,
toasters) are used for food warming or
limited cooking in accordance with
18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in
smoke compartments with 30 or fewer
patients comply with the conditions under
18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments
with 30 or fewer patients comply with
conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to
NFPA 96 per 9.2.3 are not required to be
enclosed as hazardous areas, but shall not
be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1
through 19.3.2.5.5, 9.2.3, TIA 12-2
K 0324
SS=D
Bldg. 01
1. Based on record review, observation
and interview; the facility failed to ensure
1 of 1 kitchen exhaust systems was
inspected in accordance with NFPA 96.
NFPA 96, 2011 Edition, Standard for
Ventilation Control and Fire Protection
of Commercial Cooking Operations,
Section 11.4 states the entire exhaust
system shall be inspected for grease
buildup by a properly trained, qualified,
and certified person(s) acceptable to the
authority having jurisdiction and in
accordance with Table 11.4. Table 11.4,
Schedule for Inspection for Grease
K 0324 K324 Cooking Facilities
It is the practice of this provider to
ensure that all inspections for
cooking facility equipment are done
bi-annually and inspection is
available to all authority that
request said document. Also, that a
drip tray will be installed for
continued use and safety on vent
hood.
What corrective action will be taken
for the 2 staff and visitors that could
be affected by this deficient
practice? Bi-annual inspection by
09/15/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 4 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
Buildup, requires systems serving
moderate volume cooking operations
shall be inspected semiannually. Section
11.6.1 states, upon inspection, if the
exhaust system is found to be
contaminated with deposits from grease
laden vapors, the contaminated portions
of the exhaust system shall be cleaned by
a properly trained, qualified, and
certified person(s) acceptable to the
authority having jurisdiction. Hoods,
grease removal devices, fans, ducts, and
other appurtenances shall be cleaned to
remove combustible contaminants prior
to surfaces becoming heavily
contaminated with grease or oily sludge.
After the exhaust system is cleaned, it
shall not be coated with powder or other
substance. When an exhaust cleaning
service is used, a certificate showing the
name of the servicing company, the name
of the person performing the work, and
the date of inspection or cleaning shall be
maintained on the premises. This
deficient practice could affect two staff
and visitors.
Findings include:
Based on record review with the Head of
Maintenance from 11:10 a.m. to 12:50
p.m. on 08/16/17, documentation of
semiannual kitchen exhaust system
inspection for the most recent twelve
HOODZ Job Service will be done,
with sticker affixed, and inspection
recorded by maintenance director.
Also, SafeCare will create drip tray
for hood vent for possible grease
resolution.
How other residents having the
potential to be affected by the same
defective practice will be identified
and what corrective actions will take
place? Kitchen staff workers can be
affected, along with visitors to this
area of facility. The inspections will
be done on time, recorded, and drip
tray for vent installed.
What measures will be put into
place or what systemic changes will
be made to ensure that the deficient
practice does not occur? HOODZ
Job Service is retained to do 2X a
year inspection of hood vent to
ensure safe, clean use of equipment,
and affix sticker at each inspection.
This inspection will be retained by
maintenance director and produced
when needed by requestors.
How the corrective action will be
monitored to ensure the deficient
practice will not reoccur, i.e., what
quality assurance program will be
put in place? The inspection of hood
vents and the installation of drip
tray on hood vent will be duly noted
in monthly Safety Committee
meeting in month that it takes place,
and will be reported to QAPI group
in the appropriate monthly meeting.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 5 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
month period was not available for
review. Based on interview at the time of
record review, the Head of Maintenance
stated documentation of semiannual
kitchen exhaust system inspection for the
most recent twelve month period was not
available for review. Based on
observations with the Head of
Maintenance during a tour of the facility
from 9:15 a.m. to 11:10 p.m. on
08/16/17, no inspection contractor had
affixed a sticker to the range hood in the
kitchen documenting kitchen exhaust
system inspections within the most recent
twelve month period.
3.1-19(b)
2. Based on observation and interview,
the facility failed to install the kitchen
range hood system in accordance with the
requirements of LSC 9.2.3. Section 9.2.3
states commercial cooking equipment
shall be installed in accordance with
NFPA 96, Standard for Ventilation
Control and Fire Protection of
Commercial Cooking Operations. NFPA
96, 2011 edition, Section 6.2.4.1 states
kitchen range hood system filters shall be
equipped with a drip tray beneath their
lower edges. The tray shall be kept to the
minimum size needed to collect grease
and shall be pitched to drain into an
enclosed metal container having a
This systemic change will be done by
Sept. 15, 2017.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 6 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
capacity not exceeding 1 gal (3.785 L).
This deficient practice could affect two
staff and visitors in the kitchen.
Findings include:
Based on observations with the Head of
Maintenance during a tour of the facility
from 9:15 a.m. to 11:10 p.m. on
08/16/17, the kitchen range hood system
filters were not equipped with a pitched
drip tray and was missing an enclosed
metal container for grease to drain into.
Based on interview at the time of the
observations, the Head of Maintenance
stated the kitchen range hood system had
no designated location underneath the
kitchen range hood system for a drip tray
and was missing an enclosed metal
container for grease to drain into.
3.1-19(b)
NFPA 101
Sprinkler System - Maintenance and Testing
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems
are inspected, tested, and maintained in
accordance with NFPA 25, Standard for the
Inspection, Testing, and Maintaining of
Water-based Fire Protection Systems.
K 0353
SS=F
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 7 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
Records of system design, maintenance,
inspection and testing are maintained in a
secure location and readily available.
a) Date sprinkler system last checked
_____________________
b) Who provided system test
____________________________
c) Water system supply source
__________________________
Provide in REMARKS information on
coverage for any non-required or partial
automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
1. Based on record review, observation
and interview; the facility failed to
document sprinkler system inspections in
accordance with NFPA 25. NFPA 25,
Standard for the Inspection, Testing, and
Maintenance of Water-Based Fire
Protection Systems, 2011 Edition,
Section 5.2.4.1 states gauges on wet pipe
sprinkler systems shall be inspected
monthly to ensure that they are in good
condition and that normal water supply
pressure is being maintained. Section
5.2.4.2 states gauges on dry pipe
sprinkler systems shall be inspected
weekly to ensure that normal air and
water pressures are being maintained.
Section 5.1.2 states valves and fire
department connections shall be
inspected, tested, and maintained in
accordance with Chapter 13. Section
13.1.1.2 states Table 13.1.1.2 shall be
utilized for inspection, testing and
maintenance of valves, valve components
K 0353 It is the practice of this provider to
ensure the sprinkling system and
control valves are maintained and
inspected in a safe manner .
What corrective action will be taken
for those residents that have been
affected by the deficient practice?
Weekly checks of wet and dry
sprinkling system will be inspected
and log kept showing that all gauges
are in working order. Also, that
escutcheon in 2 affected areas,
employee breakroom and
equipment room are replaced.
How other residents have the
potential to be affected by the same
deficient practice will be identified
and what corrective actions will be
taken? Maintenance director will
keep a weekly log to document that
gauges and control valves for
sprinkling system are in working
order. All residents could be affected
if gauges were not functioning
properly.
What measures will be put in place
or what systemic change will be
09/15/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 8 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
and trim. Section 4.3.1 states records
shall be made for all inspections, tests,
and maintenance of the system and its
components and shall be made available
to the authority having jurisdiction upon
request. This deficient practice could
affect all residents, staff, and visitors.
Findings include:
Based on review of SafeCare's "Report of
Inspection" documentation dated
08/29/16, 11/29/16, 02/15/17 and
05/25/17 with the Head of Maintenance
during record review from 11:10 a.m. to
12:50 p.m. on 08/16/17, weekly dry
sprinkler system gauge inspection
documentation for 48 weeks of the most
recent 52 week period was not available
for review. Monthly wet sprinkler
system gauge inspection documentation
for 8 months of the most recent 12 month
period was also not available for review.
In addition, monthly inspection
documentation for all sprinkler system
control valves for 8 months of the most
recent 12 month period was not available
for review. Based on interview at the
time of record review, the Head of
Maintenance stated the facility frequently
checks sprinkler gauges and valves but
sprinkler system gauge and control valve
inspection documentation for the
aforementioned weekly and monthly
made to ensure that the deficient
practice does not occur?
Maintenance Director will do weekly
checks, log them, and keep log book
for availability to requestors. The 2
escutcheons will be replaced in
break room and equipment room.
How the corrective action will be
monitored to ensure the deficient
practice will not occur, I.e., what
quality assurance program will be
put in place? Weekly log will be
kept by Maintenance Director, who
will report monthly to safety
committee. It will be followed as a
monthly item in QAPI for him to
report. Two escutcheons will be
replaced and any others that need
repair or replacement.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 9 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
periods was not available for review.
Based on observations with the Head of
Maintenance during a tour of the facility
from 9:15 a.m. to 11:10 p.m. on
08/16/17, the facility has supervised wet
and dry sprinkler systems.
3.1-19(b)
2. Based on observation and interview,
the facility failed to ensure 2 of over 100
sprinkler heads in the facility were
maintained. NFPA 13, Standard for the
Installation of Sprinkler Systems, 2010
Edition, Section 6.2.7.2 states
escutcheons used with recessed,
flush-type or concealed sprinklers shall
be part of a listed sprinkler assembly.
This deficient practice could affect 12
residents, staff and visitors in the vicinity
of the Employee Break Room.
Findings include:
Based on observations with the Director
of Environmental Services (DES) during
a tour of the facility from 9:15 a.m. to
11:10 p.m. on 08/16/17, the sprinkler
head located in the corridor by the
Employee Break Room and the sprinkler
head located in the Equipment Room
were both missing its respective
escutcheon. Based on interview at the
time of the observations, the DES agreed
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 10 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
the aforementioned sprinkler locations
had a missing escutcheon plate.
3.1-19(b)
NFPA 101
Portable Fire Extinguishers
Portable Fire Extinguishers
Portable fire extinguishers are selected,
installed, inspected, and maintained in
accordance with NFPA 10, Standard for
Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
K 0355
SS=D
Bldg. 01
1. Based on observation and interview,
the facility failed to ensure 1 of 15
portable fire extinguishers were readily
accessible and immediately available in
accordance with NFPA 10. NFPA 10,
Standard for Portable Fire Extinguishers,
2010 Edition, Section 6.1.3.1 states fire
extinguishers shall be readily accessible
and immediately available in the event of
a fire. Fire extinguishers shall not be
obstructed or obstructed from view. This
deficient practice could affect 2 staff and
visitors in the kitchen.
Findings include:
Based on observations with the Head of
Maintenance during a tour of the facility
K 0355 It is the practice of this provider to
ensure that all fire extinguishers In
the facility are in working order,
inspected, and installed in the
correct manner.
What corrective action will be taken
for those residents that have been
affected by the deficient practice?
The K Class fire extinguisher in the
kitchen area will be installed in the
correct bracket and hung in an area
that is unimpeded for use. Nothing
will be stored in front of the fire
extinguisher.
How other residents having the
potential to be affected by the same
deficient practice will be identified
and what corrective actions will be
taken? All kitchen staff and visitors
09/15/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 11 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
from 9:15 a.m. to 11:10 p.m. on
08/16/17, a five foot tall stack of bread
trays was placed on the floor in front of
the portable K Class fire extinguisher in
the kitchen which blocked ready access
and immediate availability for the fire
extinguisher. Based on interview at the
time of the observations, the Head of
Maintenance stated the bread trays should
not have been placed in front of the fire
extinguisher and blocked it from ready
access and immediate availability.
3.1-19(b)
2. Based on observation and interview,
the facility failed to ensure 1 of 15
portable fire extinguishers were installed
in accordance with NFPA 10. NFPA 10,
Standard for Portable Fire Extinguishers,
2010 Edition, Section 6.1.3.4 states
portable fire extinguishers other than
wheeled extinguishers shall be installed
using any of the following means:
(1) Securely on a hanger intended for the
extinguisher
(2) In the bracket supplied by the
extinguisher manufacturer
(3) In a listed bracket approved for such
purpose
(4) In cabinets or wall recesses
Section 6.1.3.8.1 states fire extinguishers
having a gross weight not exceeding 40
lb shall be installed so that the top of the
to the area could be affected by fire
extinguisher not being properly
installed and hung on wall.
What measures will be put in place
or what systemic change will be
made to ensure that the deficient
practice does not occur? A new
bracket is installed that is
appropriate for hanging a K Class
extinguisher. Kitchen staff has been
educated not to place anything in
front of extinguishing devices.
How the corrective action will be
monitored to ensure the deficient
practice will not occur, i.e., what
quality assurance program will be
put in place? The K Class fire
extinguisher has been hung in
correct bracket. Maintenance
Director will do visual inspection on
weekly basis and report to Safety
Committee and QAPI monthly
advising that all safe measures are in
place.
The systemic change will be done by
Sept. 15, 2017.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 12 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
fire extinguisher is not more than five
feet above the floor. Section 6.1.3.8.3
states in no case shall the clearance
between the bottom of the hand portable
fire extinguisher and the floor be less
than four inches. This deficient practice
could affect 2 staff and visitors in the
kitchen.
Findings include:
Based on observations with the Head of
Maintenance during a tour of the facility
from 9:15 a.m. to 11:10 p.m. on
08/16/17, the portable K Class fire
extinguisher in the kitchen was
freestanding on the floor behind a five
foot tall stack of bread trays which
blocked ready access and immediate
availability for the fire extinguisher. The
designated location on the wall for the
fire extinguisher by the K Class placard
was missing its hanger or supporting
bracket. Based on interview at the time
of observation, the Head of Maintenance
stated the kitchen staff didn't tell him the
portable fire extinguisher hanger or
supporting bracket was missing and it
should not have been placed on the floor
behind the bread trays.
3.1-19(b)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 13 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
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 1 of 1 ceiling
smoke barriers was maintained to provide
at least a one half hour fire resistance
rating. This deficient practice could
affect all residents, staff and visitors.
Findings include:
Based on observations with the Director
of Environmental Services (DES) and the
Head of Maintenance during a tour of the
facility from 9:15 a.m. to 11:10 p.m. on
08/16/17, the following was noted:
a. a two inch hole by a sprinkler
K 0372 It is the practice of this provider to
ensure that all smoke barriers are
complete and provide at least one
half hour fire resistance rating.
What corrective action will be taken
for the 4 identified areas that could
be affected by this deficient
practice? Maintenance Director to
repair a two inch hole by sprinkler
escutcheon in Janitor’s Closet by the
west nurse’s station, a one half inch
hole by sprinkler escutcheon in
ceiling above the Medical Records
desk by west nurse’s station, a three
inch hole in the ceiling by the
sprinkler escutcheon in the
Progressive Wellness Therapy Center
09/15/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 14 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
escutcheon in the ceiling of the Janitor's
Closet by the west nurse's station.
b. a one half inch hole by a sprinkler
escutcheon in the ceiling above the
Medical Records desk by the west nurse's
station.
c. a three inch hole by a sprinkler
escutcheon in the ceiling of the restroom
in the Progressive Wellness Therapy
Center in the west hall.
d. a two inch hole in the ceiling above the
"E1" Emergency Panel in the transfer
switch room.
Based on interview at the time of the
observations, the (DES) and the Head of
Maintenance agreed the holes in the
ceiling did not maintain the fire
resistance rating of the ceiling smoke
barrier.
3.1-19(b)
in the west hall, and a two inch hole
in the ceiling above the “E1”
Emergency Panel in the transfer
switch room.
How other residents having the
potential to be affected by the same
deficient practice will be identified
and what corrective actions will take
place? This deficient practice could
affect all residents, staff, and
visitors. That is why the 4 identified
areas in the ceiling have been
sealed by Maintenance Director.
What measures will be put into
place or systemic changes will be
made to ensure that the deficient
practice does not recur? All smoke
barriers will be sealed and evidence
of such be recorded to ensure the
safety of all residents, staff, and
visitors.
How the corrective action will be
monitored to ensure the deficient
practice will not recur, i.e., what
quality assurance program will be
put in place? All areas have been
sealed by Maintenance Director and
will be checked monthly prior to
Safety Committee Meeting to ensure
the integrity of the seal.
The systemic change is done, and to
be included in the Sept. 15, 2017
date.
NFPA 101 K 0374
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 15 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
Subdivision of Building Spaces - Smoke
Barrie
Subdivision of Building Spaces - Smoke
Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick
solid bonded wood-core doors or of
construction that resists fire for 20 minutes.
Nonrated protective plates of unlimited
height are permitted. Doors are permitted to
have fixed fire window assemblies per 8.5.
Doors are self-closing or automatic-closing,
do not require latching, and are not required
to swing in the direction of egress travel.
Door opening provides a minimum clear
width of 32 inches for swinging or horizontal
doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
SS=E
Bldg. 01
Based on record review, observation and
interview; the facility failed to ensure 1
of 2 rolling fire doors was maintained in
accordance with NFPA 80. LSC
19.3.7.6.2 states doors shall be permitted
to have fixed fire window assemblies in
accordance with Section 8.5. LSC
8.5.4.5 states fire window assemblies
shall comply with 8.3.3. LSC 8.3.3.1
states fire window assemblies and their
accompanying hardware, including all
frames, closing devices, anchorage and
sills shall be in accordance with the
requirements of NFPA 80, Standard for
Fire Doors and Other Openings
Protectives. NFPA 80, 2010 Edition,
Section 5.2 states fire door assemblies
shall be inspected and tested not less than
annually, and a written record of the
K 0374 It is the practice of this provider to
ensure that all inspections for rolling
fire doors in the kitchen area are
available, completed, tagged, and
current.
What corrective action will be
accomplished for those residents
found to be affected by the deficient
practice? SafeCare did a full
inspection on the rolling fire door,
tagged it, and documented it to the
Maintenance Director.
How other residents having the
potential to be affected by the same
deficient practice will be identified
and what corrective actions will be
taken? The deficient practice could
affect 20 residents, staff, and visitors
in the main dining room.
What measures will be put in place
09/15/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 16 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
inspection shall be signed and kept for
inspection by the authority having
jurisdiction. This deficient practice could
affect 20 residents, staff and visitors in
the main dining room.
Findings include:
Based on record review with the Head of
Maintenance from 11:10 a.m. to 12:50
p.m. on 08/16/17, documentation of
annual rolling fire door inspection within
the most recent twelve month period was
not available for review. Based on
observations with the Head of
Maintenance during a tour of the facility
from 9:15 a.m. to 11:10 p.m. on
08/16/17, two metal horizontal rolling
fire doors were noted in the smoke
barrier wall separating the kitchen from
the main dining room. SafeCare had
affixed a maintenance tag to the rolling
fire door for the dish return/dish washing
area indicating an inspection was
performed on 02/16/17 but annual
inspection documentation within the
most recent twelve month period for the
rolling fire door at the serving window
was not affixed to the rolling fire door.
Based on interview at the time of record
review and of the observations, the Head
of Maintenance stated he had SafeCare
service the dish area rolling fire door in
February 2017 but stated documentation
or what systemic changes will be
made to ensure that the deficient
practice does not recur? The annual
inspection by SafeCare will be
documented, tagged, and recorded
by Maintenance Director and
available for inspection.
How the corrective action will be
monitored to ensure the deficient
practice will not recur, i.e., what
quality assurance program will be
put in place? Maintenance Director
will schedule and make sure that
rolling door inspection for barrier
are done annually, and kept in log
that is available. When completed
annually it will be reported to Safety
Committee and QAPI in the month
that it takes place.
The systemic change will be done by
Sept. 15, 2017.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 17 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
of annual rolling fire door inspection
within the most recent twelve month
period for the serving window rolling fire
door was not available for review.
3.1-19(b)
NFPA 101
Fire Drills
Fire Drills
Fire drills include the transmission of a fire
alarm signal and simulation of emergency
fire conditions. Fire drills are held at
unexpected times under varying conditions,
at least quarterly on each shift. The staff is
familiar with procedures and is aware that
drills are part of established routine.
Responsibility for planning and conducting
drills is assigned only to competent persons
who are qualified to exercise leadership.
Where drills are conducted between 9:00
PM and 6:00 AM, a coded announcement
may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through
19.7.1.7
K 0712
SS=F
Bldg. 01
Based on record review and interview,
the facility failed to provide
documentation of a fire drill conducted
on the second and third shifts for 1 of 4
quarters. This deficient practice affects
all residents, staff and visitors.
Findings include:
K 0712 It is the practice of this provider to
ensure that all fire drills are done in
accordance with regulation for the
safety of all staff, residents, and
visitors in the facility.
What corrective actions will be
accomplished for those residents
found to be affected by the deficient
practice? Fire Drills will be
scheduled at unexpected times on
09/15/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 18 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
Based on review of "Fire Drill Report"
documentation with the Head of
Maintenance during record review from
11:10 a.m. to 12:50 p.m. on 08/16/17,
documentation of a fire drill conducted
on the second shift in the fourth quarter
(October, November, December) of 2016
and documentation of a fire drill
conducted on the third shift in the first
quarter (January, February, March) of
2017 was not available for review. Based
on interview at the time of record review,
the Head of Maintenance stated they
conduct quarterly fire drills on each shift
once per quarter but documentation for
fire drills conducted on the
aforementioned shifts and quarters was
not available for review.
3.1-19(b)
every shift at least quarterly and
documented through a signed log
book kept by Maintenance Director.
How other residents having the
potential to be affected by the same
deficient practice will be identified
and what corrective actions will take
place? The deficient practice could
affect all residents, staff, and
visitors.
What measure will be put into place
or systemic changes will be made to
ensure that the deficient practice
does not recur? All quarterly fire
drills will be reported for each shift
by the Maintenance Director to the
Safety Committee and duly noted in
QAPI in the month they take place.
How the corrective action will be
monitored to ensure the deficient
practice will not recur, i.e., what
quality assurance program will be
put in place? The Maintenance
Director will keep a log of all fire
drills for each shift, report it to the
Safety Committee in the month that
it takes place, and, also, report it to
the monthly QAPI committee at
least quarterly per the regulation.
The systemic change will be done by
Sept. 15, 2017.
NFPA 101
Smoking Regulations
Smoking Regulations
K 0741
SS=E
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 19 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
Smoking regulations shall be adopted and
shall include not less than the following
provisions:
(1) Smoking shall be prohibited in any room,
ward, or compartment where flammable
liquids, combustible gases, or oxygen is
used or stored and in any other hazardous
location, and such area shall be posted with
signs that read NO SMOKING or shall be
posted with the international symbol for no
smoking.
(2) In health care occupancies where
smoking is prohibited and signs are
prominently placed at all major entrances,
secondary signs with language that prohibits
smoking shall not be required.
(3) Smoking by patients classified as not
responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not
apply where the patient is under direct
supervision.
(5) Ashtrays of noncombustible material and
safe design shall be provided in all areas
where smoking is permitted.
(6) Metal containers with self-closing cover
devices into which ashtrays can be emptied
shall be readily available to all areas where
smoking is permitted.
18.7.4, 19.7.4
Based on record review, observation and
interview; the facility failed to ensure
smoking materials were deposited into
ashtrays and metal containers with
self-closing cover devices into which
ashtrays can be emptied of
noncombustible material and safe design
in 1 of 1 outdoor areas where smoking is
permitted. This deficient practice could
affect five residents, staff and visitors in
the courtyard smoking area.
K 0741 It is the practice of this provider to
ensure that all smoking materials in
the smoking area are disposed of in
accordance with regulations for said
practice.
What corrective actions will be
accomplished for those residents
found to have been affected by the
deficient practice? Ash trays will be
provided for smokers in the smoking
area and metal containers will be
09/15/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 20 of 21
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
09/27/2017PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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 46222
155389 08/16/2017
WESTPARK A WATERS COMMUNITY
1316 N TIBBS AVE
01
Findings include:
Based on record review from 11:10 a.m.
to 12:50 p.m. on 08/16/17, the Head of
Maintenance stated the facility's current
policy is assessed residents are allowed to
smoke with staff supervision in the
courtyard area. Based on observations
with the Head of Maintenance during a
tour of the facility from 9:15 a.m. to
11:10 a.m. on 08/16/17, over 50 cigarette
butts were strewn on the ground outside
the facility in the courtyard resident
smoking area. A smoking tower for
depositing smoking materials was present
at the location. Based on interview at the
time of the observations, the Head of
Maintenance stated staff are present when
residents are smoking at this outdoor
location and but stated ashtrays and metal
containers were not being used
consistently by residents at this
aforementioned location where resident
smoking was taking place.
3.1-19(b)
provided for emptying the ash trays
and readily available in this area.
How other residents having the
potential to be affected by the same
deficient practice will be identified
and what corrective actions will take
place? The deficient practice could
affect five residents, staff, and
visitors in the smoking area.
What measures will be put into
place or what systemic changes will
be made to ensure that the deficient
practice does not recur? The facility
will provide ample ash trays in the
smoking area, supervision will
ensure they are used, and they will
be emptied into metal containers
provided in the smoking area.
How the corrective actions will be
monitored to ensure the deficient
practice will not recur, i.e., what
quality assurance program will be
put in place? The smoking area will
be maintained by supervising staff
and part of the monthly Safety
Committee with a report by
Maintenance Director. This report
will be included in QAPI meeting
monthly for 3 months or until no
more needed resolution for K741 is
needed.
The systemic change will be done by
Sept., 15, 2017.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2Q8J21 Facility ID: 000473 If continuation sheet Page 21 of 21