(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
--
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: 10/08/19
Facility Number: 000303
Provider Number: 155708
AIM Number: 100287530
At this Emergency Preparedness survey, Hillside
Manor Nursing Home was found in substantial
compliance with Emergency Preparedness
Requirements for Medicare and Medicaid
Participating Providers and Suppliers, 42 CFR
483.73
The facility has a capacity of 48 certified beds and
had a census of 44 at the time of this visit.
Quality Review completed on 10/16/19
E 0000 Please accept the following POC
as our credible allegation of
compliance.
A desk review is requested. See
attached Copy of sprinkler system
weekly checks, disaster
preparedness policies, and
in-services applicable to disaster
preparedness and related
education.
E 0009
SS=C
Bldg. --
Based on record review and interview, the facility
failed to ensure the emergency preparedness plan
included a process for cooperation and
collaboration with local, tribal, regional, State, or
Federal emergency preparedness officials' efforts
to maintain an integrated response during a
disaster or emergency situation, including
documentation of the LTC facility's efforts to
contact such officials and, when applicable, of its
participation in collaborative and cooperative
planning efforts in accordance with 42 CFR
483.73(a)(4). This deficient practice could affect all
E 0009 Hillside Manor shall maintain an
emergency preparedness plan that
shall include collaborative
participation by local and state
agencies and participating
healthcare facilities. Hillside
Manor has maintained an
emergency preparedness policy
manual (plan) since OBRA 87. It
is and has been updated and
revised ANNUALLY by changing
guidelines and contributing
11/07/2019 12:00:00AM
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: GFZK21 Facility ID: 000303
TITLE
If continuation sheet Page 1 of 23
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
--
occupants.
Findings include:
Based on review of the Emergency Preparedness
Program on 10/08/19 between 9:15 a.m. and 11:30
a.m. with the former Maintenance Supervisor and
Maintenance Supervisor-in-training present, no
documentation was available which included a
process for cooperation and collaboration with
local, tribal, regional, State, or Federal emergency
preparedness officials' efforts to maintain an
integrated response during a disaster or
emergency situation. Based on interview at the
time of review, the former Maintenance Supervisor
confirmed a cooperation and collaboration
process was not in the Emergency Preparedness
Program.
agencies. This emergency
management policy book is kept
in the administrators office along
with all policy and procedure
manuals (not available to new or
past maintenance supervisors in
the HFA absence). it was not
available to the inspector until after
2pm the day of the survey. it was
not located by the new or past
maintenance supervisor.
No changes or additions need to
be made to improve the existing
disaster and emergency policy
and procedure manual. It shall be
maintained and updated annually
by the HFA.
The HFA shall be responsible to
maintain, update, and review
annually the disaster
preparedness policy and plan.
E 0024
SS=C
Bldg. --
Based on record review and interview, the facility
failed to ensure emergency preparedness policies
and procedures include the use of volunteers in
an emergency or other emergency staffing
strategies, including the process and role for
integration of State or Federally designated health
care professionals to address surge needs during
an emergency in accordance with 42 CFR
483.73(b)(6). This deficient practice could affect
all occupants.
Findings include:
E 0024 Hillside Manor shall develop and
implement emergency
preparedness policies and
procedures to detail the use of
volunteers during surge needs.
No residents were affected for the
lack of policy but could be
potentially affected if a large scale
emergency situation occurred.
The facility created an addendum
to the current emergency
11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 2 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
--
Based on review of the Emergency Preparedness
Program on 10/08/19 between 9:15 a.m. and 11:30
a.m. with the former Maintenance Supervisor and
Maintenance Supervisor-in-training present, the
facility's plan did not address the use of
volunteers in an emergency. Based on interview
at the time of review, the former Maintenance
Supervisor agreed the plan did not address the
use of volunteers in an emergency.
preparedness program specifically
addressing the use of volunteers
during surge needs effective
10-28-2019.
The facility administrator is
responsible for making sure the
policy and procedures are
implemented and signed off each
year.
E 0039
SS=C
Bldg. --
Based on record review and interview, the facility
failed to provide complete documentation of
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
E 0039 Hillside Manor shall participate in
a community based exercise of a
natural or man-made emergency
when offered. There hasn't been an
offering since September of 2018.
Hillside Manor is a connected
participant in our county EMA
(Emergency Management
Agency). By being attached to a
code "RED" alert, we, as others
will get total support from
healthcare agencies, police, fire,
and other support such as food,
water, shelter, etc. Hillside Manor
shall conduct a scheduled "table
top" exercise on 10/30/2019 with
Capt. JR Crew of the Daviess
County Sheriffs Dept on shooters
and guns in the workplace.
Hillside Manor shall add to the
disaster and emergency plan an
annual full scale exercise with the
city of Washington or a facility
based emergency exercise
un-announced and evaluate the
11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 3 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
--
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 the Emergency Preparedness
Program on 10/08/19 between 9:15 a.m. and 11:30
a.m. with the former Maintenance Supervisor and
Maintenance Supervisor-in-training present, the
facility was unable to provide documentation of
two exercises within the past twelve months.
Based on interview at the time of record review,
the former Maintenance Supervisor said the
facility did not conduct two exercises from their
Emergency Preparedness Program during the past
12 months, but have upcoming exercises planned.
response by the staff. Failure to
do so, however remote, could
affect the safety of all residents
and employees.
For the past 37 years Hillside
Manor has provided training to the
staff twice a year on fire,
emergency evacuation, and
disaster preparedness and
response. This has always been
evaluated with a pre and post test
questionnaire to test the staffs
proper response. Hillside Manor
shall add to this a full scale city
emergency exercise or a facility
based only exercise of man made
or natural disasters such as guns
in the workplace, or bomb threats.
The city EMA manager reported a
Table top exercise was held in
Sept of 2018 and no additional
exercises are planned until 2020.
The facility HFA shall be
responsible for conducting and
recording two such annual
exercises and the proper or
un-proper responses from
participating staff.
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: 10/08/19
K 0000 Please accept the following POC
as our credible allegation of
compliance.
A desk review is requested. See
attached Copy of sprinkler system
weekly checks, disaster
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 4 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
Facility Number: 000303
Provider Number: 155708
AIM Number: 100287530
At this Life Safety Code survey, Hillside Manor
Nursing Home 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 original portion of the facility was a one
story facility with a basement and was determined
to be of Type V (000) construction and was fully
sprinklered. The 2002 addition east-west corridor
at the south end of the facility, including resident
rooms 16 through 24, was a one story facility
determined to be of Type V (111) construction and
was fully sprinklered. The facility has a fire alarm
system with hard wired smoke detectors on both
levels including the corridors, spaces open to the
corridors, and all resident sleeping rooms. The
facility has a capacity of 48 and had a census of
44 at the time of this survey.
Quality Review completed on 10/16/19
preparedness policies, and
in-services applicable to disaster
preparedness and related
education.
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.
K 0211
SS=E
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 5 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
18.2.1, 19.2.1, 7.1.10.1
Based on observation and interview, the facility
failed to ensure 1 of 3 corridor means of egress
was continuously maintained free of obstructions.
This deficient practice affects up to 8 residents, as
well as staff and visitors.
Findings include:
Based on observation on 10/08/19 at 11:57 a.m.
during a tour of the facility with the former
Maintenance Supervisor and Maintenance
Supervisor-in-training, there was a wheel chair
scale located in the corridor across from room 4.
Based on an interview at the time of observation,
the former Maintenance Supervisor said he was
unaware the wheel chair scale could not be stored
in the corridor.
3.1-19(b)
K 0211 Hillside Manor nursing home shall
maintain passageways, Corridors,
and halls and keep them free and
clear of any obstructions limiting
egress in the case of emergency.
While a floor scale in one hallway
may have affected potentially only
eight residents the consequence
of hallway obstruction for
emergency egress could affect all.
New policies and procedures are
not required in this one time
simple fix of removing the floor
scale from the hallway. This was
completed on 10-8-2019 the day of
the survey.
The new maintenance supervisor
shall be responsible for
maintaining all hallways free of
any obstructions. The quality
assurance committee shall
quarterly check on this issue to
assure of its resolve for the next 3
quarters.
11/07/2019 12:00:00AM
NFPA 101
Fire Alarm System - Testing and
Maintenance
Fire Alarm System - Testing and
Maintenance
A fire alarm system is tested and maintained
in accordance with an approved program
complying with the requirements of NFPA 70,
National Electric Code, and NFPA 72,
National Fire Alarm and Signaling Code.
Records of system acceptance, maintenance
K 0345
SS=F
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 6 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Based on record review and interview, the facility
failed to maintain 1 of 1 fire alarm systems in
accordance with NFPA 72, as required by LSC 101
Sections 19.3.4.5.1 and 9.6. NFPA 72, Section
14.3.1 states that unless otherwise permitted by
14.3.2, visual inspections shall be performed in
accordance with the schedules in Table 14.3.1, or
more often if required by the authority having
jurisdiction. Table 14.3.1 states that the following
must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual
fire alarm boxes, heat detectors, smoke detectors,
etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all occupants
in the facility.
Findings include:
Based on record review on 10/08/19 between 9:15
a.m. and 11:30 a.m. with the former Maintenance
Supervisor and Maintenance
Supervisor-in-training present, no documentation
could be provided regarding a visual semi-annual
fire alarm system inspection. Based on interview
at the time of record review, the former
Maintenance Supervisor said that visual
inspections of the fire-alarm system's devices
were not performed on a semi annual basis.
3.1-19(b)
K 0345 Hillside Manor nursing home
continues to maintain a visual
inspection of the fire alarm system
with proper monthly recordings
during fire alarm testing. See
enclosed copy of monthly exams
of such during alarm testing.
Magnetic hold open devices,
remote annunciator’s and strobes,
control units and automatic dialer
for assistance, and pull stations or
all visually checked monthly and
so recorded. The smoke detectors
visually scan and monthly during
the fire drill. The individual alarms
are tested annually (unless new
installed)by an outside
professional agent who also is
responsible for recalibrating or
replacing unit not intolerance. As
safety for all of our residents is of
importance the maintenance
supervisor will turn in a log of such
monthly exams to the
administrator who shall properly
file the records. Magnetic hold
open devices, remote
annunciator‘s and strobes, control
units and automatic dialer for
assistance, and pull stations or all
visually checked monthly and so
recorded. The smoke detectors
visually scanned monthly during
the fire drill. The individual alarms
are tested annually parentheses
unless new installed parentheses
by an outside professional agent
11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 7 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
who also is responsible for
recalibrating or replacing units not
intolerance. As safety for all of our
residence is of importance the
maintenance supervisor will turn in
a log of such monthly exams to
the administrator who shall
properly file the recordings.
A new form or policy does not
need to be implemented, but
rather needs to be available for
exam in the administrators
absence.
The administrator shall be
responsible for the maintenance
department conducting such
monthly exams, required
semiannually and maintaining the
file for exam.
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.
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
__________________________
K 0353
SS=C
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 8 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
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
Based on record review, observation and
interview; the facility failed to provide complete
documentation sprinkler system inspections were
in accordance with NFPA 25 for 1 of 1 dry
sprinkler systems. NFPA 25, Standard for the
Inspection, Testing, and Maintenance of
Water-Based Fire Protection Systems, 2011
Edition, 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 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 in the facility.
Findings include:
Based on record review on 10/08/19 between 9:15
a.m. and 11:30 a.m. with the former Maintenance
Supervisor and Maintenance
Supervisor-in-training present, there was
documentation available quarterly sprinkler
inspections were performed on 11/27/18, 03/19/19,
06/12/19 and 08/30/19. Weekly dry sprinkler
system gauge inspection documentation for 13 of
the most recent 52 week period was not available
for review for the dry sprinkler system. In
addition, monthly inspection documentation for
K 0353 The Hillside Manor nursing home
sprinkler system is tested
quarterly by an outside
professional company. This
company has provided
professional service to our facility
since 1982. They conduct required
test quarterly including a timed trip
test annually. They test and
examine all valves and gauges for
proper function. The maintenance
department visually examines the
control valve and water and air
pressure gauges weekly and
records search. See enclosed
copy.
No resident has been exposed to
unwanted risk or harm by this
missed filed Visual gauges and
valve examination.
The maintenance department shall
continue to visually inspect such
gauges and the system control
valves and document weekly. In
the past 37 years we have
experienced three compressor
failures resulting in low air
pressure allowing the wet system
to “trip” this also triggers the
alarm system and automatic dialer
to the fire department.
The enclosed logs were found in
our log book filed under a different
11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 9 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
the sprinkler system control valves for 2 months
of the most recent 12 month period was also not
available for review. Based on interview at the
time of record review, the former Maintenance
Supervisor indicated the facility performs regular
visual sprinkler system inspections but does not
have sprinkler system gauge inspection
documentation since June 26, 2019 available for
review. Based on observations with the former
Maintenance Supervisor and Maintenance
Supervisor-in-training during a tour of the facility
from 11:30 a.m. to 1:00 p.m. the facility had 2
gauges at the sprinkler riser.
3.1-19(b)
category and were completed for
all weeks thus far of 2019.
To assure these logs are not miss
filed, a change in policy shall see
these recordings attached to the
actual sprinkler gauges for a
period of one year.
It shall be the responsibility of the
new maintenance supervisor to
both record and assure the log
remains attached to the sprinkler
gauges located in the
maintenance office. The quality
assurance committee shall review
for compliance for the next 3
quarters.
NFPA 101
Utilities - Gas and Electric
Utilities - Gas and Electric
Equipment using gas or related gas piping
complies with NFPA 54, National Fuel Gas
Code, electrical wiring and equipment
complies with NFPA 70, National Electric
Code. Existing installations can continue in
service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2
K 0511
SS=D
Bldg. 01
Based on observation and interview, the facility
failed to ensure 3 of over 5 wet locations, were
provided with ground fault circuit interrupter
(GFCI) protection against electric shock. NFPA
70, NEC 2011 Edition at 210.8 Ground-Fault
Circuit-Interrupter Protection for Personnel,
states, ground-fault circuit-interruption for
personnel shall be provided as required in
210.8(A) through (C). The ground-fault
circuit-interrupter shall be installed in a readily
accessible location.
K 0511 Hillside Manor shall maintain all
GFI outlets in wet locations in a
functional and tested fashion.
Serious harm or shock to
employees or residents could
happen if the GFI installed unit did
not perform as designed.
As all GFI plug in units were
tested, The three found to be out
11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 10 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
Informational Note: See 215.9 for ground-fault
circuit interrupter protection for personnel on
feeders.
(B) Other Than Dwelling Units. All 125-volt,
single-phase, 15- and 20-ampere receptacles
installed in the locations specified in 210.8(B)(1)
through (8) shall have ground-fault
circuit-interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Outdoors
Exception No. 1 to (3) and (4): Receptacles that are
not readily accessible and are supplied by a
branch circuit dedicated to electric snow-melting,
deicing, or pipeline and vessel heating equipment
shall be permitted to be installed in accordance
with 426.28 or 427.22, as applicable.
Exception No. 2 to (4): In industrial establishments
only, where the conditions of maintenance and
supervision ensure that only qualified personnel
are involved, an assured equipment grounding
conductor program as specified in 590.6(B)(2)
shall be permitted for only those receptacle
outlets used to supply equipment that would
create a greater hazard if power is interrupted or
having a design that is not compatible with GFCI
protection.
(5) Sinks - where receptacles are installed within
1.8 m (6 ft.) of the outside edge of the sink.
Exception No. 1 to (5): In industrial laboratories,
receptacles used to supply equipment where
removal of power would introduce a greater
hazard shall be permitted to be installed without
GFCI protection.
Exception No. 2 to (5): For receptacles located in
patient bed locations of general care or critical
care areas of health care facilities other than those
covered under
210.8(B)(1), GFCI protection shall not be required.
of compliance were replaced with
the exception of the unit 3 feet
from the hopper in the soiled utility
room. It has no power to it and
hasn’t for years and it is unused. It
was blocked off with a blank plate.
The other two were replaced on
the day of the survey.
A GFI tester was purchased on
October 25, 2019 and all units will
be tested annually.
It shall be the responsibility of the
new maintenance manager to
annually test all GFI outlets and
any new installs and replace any
that do not pass the test.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 11 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
(6) Indoor wet locations
(7) Locker rooms with associated showering
facilities
(8) Garages, service bays, and similar areas where
electrical
diagnostic equipment, electrical hand tools.
NFPA 70, 517-20 Wet Locations, requires all
receptacles and fixed equipment within the area of
the wet location to have ground-fault circuit
interrupter (GFCI) protection. Note: Moisture can
reduce the contact resistance of the body, and
electrical insulation is more subject to failure.
This deficient practice could affect at least 2
resident and staff.
Findings include:
Based on observations on 10/08/19 between 11:30
a.m. and 1:00 p.m. during a tour of the facility with
the former Maintenance Supervisor and
Maintenance Supervisor-in-training, the following
was noted:
a. One electric receptacle within three feet of the
hopper sink and regular sink in the north unit
Soiled Utility Room was provided with a GFCI
receptacle, however, when tested with a GFCI
testing device the receptacle did not trip. The
GFCI tester revealed the receptacle was
incorrectly wired and had an Open Ground.
b. One electric receptacle within two feet of the
sink in the north Shower Room was provided with
a GFCI receptacle, however, when tested with a
GFCI testing device the receptacle did not trip.
The GFCI tester revealed the receptacle was
incorrectly wired and had an Open Ground.
c. One electric receptacle within two feet of the
sink in the south Shower Room was provided with
a GFCI receptacle, however, when tested with a
GFCI testing device the receptacle did not trip.
The GFCI tester revealed the receptacle was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 12 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
incorrectly wired and had an Open/Neutral.
Based on interview at the time of observations,
the former Maintenance Supervisor agreed the
receptacles were not properly wired and said the
receptacles would be replaced as soon as
possible.
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
1. Based on record review and interview, the
facility failed to provide quarterly fire drill
documentation for 1 of 3 shifts during 3 of 4
quarters. This deficient practice could affect all
residents in the facility.
Findings include:
Based on review of the facility's fire drill reports
on 10/08/19 between 9:15 a.m. and 11:30 a.m. with
the former Maintenance Supervisor and
Maintenance Supervisor-in-training present, the
facility lacked fire drill documentation for the third
shift (night) of the first quarter (January, February,
and March), second shift (April, May, and June),
and third quarter (July, August, and September) of
K 0712 Hillside Manor nursing home shall
maintain reports and conduct
monthly fire drills in accordance to
NFPA 101 guidelines.
Properly conducted and recorded
simulated fire drills are very
important to the safety and welfare
of our residence and the facility
structure. No inconvenience shall
be found by not doing the testing
properly. No perceived or actual
harm to residence occurred.
The new maintenance supervisor
in training shall be instructed and
11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 13 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
2019. Based on interview at the time of record
review, the former Maintenance Supervisor said
there was no other documentation available for
missing fire drills during the first, second, and
third quarters of the third shift of 2019.
3.1-19(b)
2. Based on record review and interview, the
facility failed to ensure 3 of 11 fire drill reports
included proper documentation of the
transmission of a fire alarm signal to the
monitoring company/fire department during the
past twelve months, furthermore, the facility failed
to include complete information, including staff
signatures for 2 of 11 fire drills during the past
twelve months. LSC 19.7.1.4 requires fire drills in
health care occupancies shall include the
transmission of the fire alarm signal and
simulation of emergency conditions. This
deficient practice could affect all residents.
Findings include:
Based on review of the facility's fire drill reports
on 10/08/19 between 9:15 a.m. and 11:30 a.m. with
the former Maintenance Supervisor and
Maintenance Supervisor-in-training present,
documentation for 3 of 11 fire drills performed
during the past twelve months did not include
information for the transmission of the fire alarm
test to the monitoring company. This included
fire drills performed on 05/23/19, 07/01/19, and
08/23/19. Furthermore, fire drills dated 10/15/18
and 11/15/18 did not include staff signatures of
the staff who participated in the fire drills. Based
on interview at the time of record review, the
former Maintenance Supervisor said there was no
documentation available to show the monitoring
company received the transmission of the fire
educated on when and how to
properly conduct the fire drills and
the alarm testing. This individual
has been re-and serviced by the
outgoing supervisor.
These monthly drills shall very in
times, properly tested and
recorded with signatures, times,
and dates by all participants. A
successful transmission of the
automatic alarm signal shall be
properly recorded with the name,
date, and time of the person
receiving the successful
transmission signal at the Daviess
County security Center.
The maintenance supervisor shall
be responsible for timely fire drills
and the proper records of such.
The quality assurance committee
shall review for exacting and
proper compliance for the next 3
quarters.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 14 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
alarm tests for 3 of 11 fire drills during the past
twelve month period or signatures of staff
members who participated in 2 of 11 fire drills.
3-1.19(b)
NFPA 101
Smoking Regulations
Smoking Regulations
Smoking regulations shall be adopted and
shall include not less than the following
provisions:
(1) Smoking shall be prohibited in any room,
ward, or compartment where flammable
liquids, combustible gases, or oxygen is
used or stored and in any other hazardous
location, and such area shall be posted with
signs that read NO SMOKING or shall be
posted with the international symbol for no
smoking.
(2) In health care occupancies where
smoking is prohibited and signs are
prominently placed at all major entrances,
secondary signs with language that prohibits
smoking shall not be required.
(3) Smoking by patients classified as not
responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not
apply where the patient is under direct
supervision.
(5) Ashtrays of noncombustible material and
safe design shall be provided in all areas
where smoking is permitted.
(6) Metal containers with self-closing cover
devices into which ashtrays can be emptied
shall be readily available to all areas where
smoking is permitted.
18.7.4, 19.7.4
K 0741
SS=E
Bldg. 01
Based on observation and interview, the facility
failed to ensure cigarette butts were properly K 0741 Hillside Manor smoking policy for
residence and employee shall be 11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 15 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
disposed of at 1 of 1 area where cigarettes were
not supposed to be smoked. This deficient
practice could affect at least over 10 residents, as
well as staff and visitors while exiting the side
entrance/exit near the kitchen.
Findings include:
Based on observation on 10/08/19 at 12:03 p.m.
during a tour of the facility with the former
Maintenance Supervisor and Maintenance
Supervisor-in-training, there where at least 100
cigarette butts in an open container attached to
the top of a large trash can outside the side
entrance/exit near the kitchen. This was
acknowledged by the former Maintenance
Supervisor at the time of observation, who also
said cigarettes were not supposed to be smoked
anywhere other than the dedicated smoking area.
3.1-19(b)
in compliance with state and
federal regulations. A designated
smoking area with metal closure
does exist. The cited area of
cigarette butts outside and near
the kitchen was a no smoking
area. These butts were deposited
by incoming workers before they
entered the building. Staff is not
allowed to take smoke breaks in
this area.
No resident harm occurred.
A proper receptacle to receive
such cigarette butts will be placed
23 feet from the kitchen entry
door. This receptacle will be
placed to properly dispose of a
cigarette butt before entering the
workplace.
The administrator or her designee,
the director of nursing, shall
monitor and be responsible for
proper smoking compliance for the
next 12 months.
NFPA 101
Electrical Systems - Maintenance and
Testing
Electrical Systems - Maintenance and
Testing
Hospital-grade receptacles at patient bed
locations and where deep sedation or general
anesthesia is administered, are tested after
initial installation, replacement or servicing.
Additional testing is performed at intervals
defined by documented performance data.
K 0914
SS=F
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 16 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
Receptacles not listed as hospital-grade at
these locations are tested at intervals not
exceeding 12 months. Line isolation monitors
(LIM), if installed, are tested at intervals of
less than or equal to 1 month by actuating
the LIM test switch per 6.3.2.6.3.6, which
activates both visual and audible alarm. For
LIM circuits with automated self-testing, this
manual test is performed at intervals less
than or equal to 12 months. LIM circuits are
tested per 6.3.3.3.2 after any repair or
renovation to the electric distribution system.
Records are maintained of required tests and
associated repairs or modifications,
containing date, room or area tested, and
results.
6.3.4 (NFPA 99)
Based on observation, record review and
interview; the facility failed to ensure all
nonhospital-grade electrical receptacles in 26 of 26
resident room locations were tested at least
annually. NFPA 99, Health Care Facilities Code
2012 Edition, Section 6.3.4.1.3 states receptacles
not listed as hospital-grade, at patient bed
locations and in locations where deep sedation or
general anesthesia is administered, shall be tested
at intervals not exceeding 12 months.
Additionally, Section 6.3.3.2, Receptacle Testing
in Patient Care Rooms requires the physical
integrity of each receptacle shall be confirmed by
visual inspection. The continuity of the
grounding circuit in each electrical receptacle shall
be verified. Correct polarity of the hot and neutral
connections in each electrical receptacle shall be
confirmed; and retention force of the grounding
blade of each electrical receptacle (except
locking-type receptacles) shall be not less than
115 grams (4 ounces). This deficient practice
could affect all residents.
K 0914 Hillside Manor nursing home shell
annually test all resident room
nonlisted hospital grade
receptacles for compliance to
NFPA 99, healthcare facilities
code 2012 addition, section
6.3.4.2.3. The receptacle shall
have the correct polarity and
retention force, not less than 4
ounces.
Compliance shall be achieved. All
resident room receptacles were
tested for retention force and
polarity on October 14, 2019.
Three of the 291 failed the test and
were replaced with hospital grade
receptacles.
To assist with this annual
inspection, the proper testing
equipment was purchased to
determine the polarity and also to
11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 17 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
Findings include:
Based on record review on 10/08/19 between 9:15
a.m. and 11:30 a.m. with the former Maintenance
Supervisor and Maintenance
Supervisor-in-training present, there was no
record of an annual test for each resident room
electrical receptacle that was not a hospital-grade
receptacle. Based on interview at the time of
record review, the former Maintenance Supervisor
said all of the electrical receptacles in resident
rooms were not hospital-grade receptacles as far
as he knew. He further said there was no record
or documentation to show that annual testing per
NFPA 99, Receptacle Testing requirements was
met. Based on observations between 11:30 a.m.
and 1:00 p.m. during a tour of the facility with the
former Maintenance Supervisor and Maintenance
Supervisor-in-training, there were at least four to
six electrical receptacles in each of the resident
rooms.
3.1-19(b)
measure the retention force of the
receptacle. Additionally a dozen
hospital gray plug-in receptacles
were ordered for any future
replacements.
The maintenance supervisor shall
be responsible for the annual
testing of all receptacles. The
replacement of any not passing
testing, and the proper recording
of search on a newly created form
for such purpose. These forms
shall be kept in the same logbook
as all other testing reports.
The quality assurance committee
shall review the completion of the
new form in the annual testing for
the next 3 quarters.
NFPA 101
Electrical Systems - Essential Electric Syste
Electrical Systems - Essential Electric
System Maintenance and Testing
The generator or other alternate power
source and associated equipment is capable
of supplying service within 10 seconds. If the
10-second criterion is not met during the
monthly test, a process shall be provided to
annually confirm this capability for the life
safety and critical branches. Maintenance
and testing of the generator and transfer
switches are performed in accordance with
NFPA 110.
Generator sets are inspected weekly,
exercised under load 30 minutes 12 times a
K 0918
SS=F
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 18 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
year in 20-40 day intervals, and exercised
once every 36 months for 4 continuous hours.
Scheduled test under load conditions include
a complete simulated cold start and
automatic or manual transfer of all EES
loads, and are conducted by competent
personnel. Maintenance and testing of stored
energy power sources (Type 3 EES) are in
accordance with NFPA 111. Main and feeder
circuit breakers are inspected annually, and a
program for periodically exercising the
components is established according to
manufacturer requirements. Written records
of maintenance and testing are maintained
and readily available. EES electrical panels
and circuits are marked, readily identifiable,
and separate from normal power circuits.
Minimizing the possibility of damage of the
emergency power source is a design
consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110,
NFPA 111, 700.10 (NFPA 70)
1. Based on record review and interview, the
facility failed to maintain a complete written record
of monthly generator load testing for 1 of 1
generator during 1 of the past 12 months. Chapter
6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly
testing of the generator serving the emergency
electrical system to be in accordance with NFPA
110, the Standard for Emergency and Standby
Powers Systems, Chapter 8. Chapter 6.4.4.2 of
NFPA 99 requires a written record of inspection,
performance, exercising period, and repairs for the
generator to be regularly maintained and available
for inspection by the authority having
jurisdiction. This deficient practice could affect all
residents, staff and visitors.
Findings include:
K 0918 Hillside Manor nursing home shall
maintain a weekly generator
testing log.
The testing log, that has been
properly recorded for years, was
not completed or missed placed
by the new maintenance
supervisor for the month of
September 2019. This omission or
Error did not place any residents
in jeopardy as our 13 KW
generator is only a convenience
and partial back up system and is
not designed to provide life-support
or full facility coverage.
The newly hired maintenance
11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 19 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
Based on record review on 10/08/19 between 9:15
a.m. and 11:30 a.m. with the former Maintenance
Supervisor and Maintenance
Supervisor-in-training present, there was no
monthly generator load test documentation
available for September of 2019. Based on
interview at the time of record review, the former
Maintenance Supervisor confirmed there was no
emergency generator load test documentation
available for September of 2019.
3.1-19(b)
2. Based on record review and interview, the
facility failed to ensure a written record of weekly
inspections for 1 of 1 generator was maintained
for 5 of 52 weeks. Chapter 6-4.4.1.3 of 2012 NFPA
99 requires batteries for on-site generators shall
be maintained in accordance with NFPA 110, 2010
Edition, Standard for Emergency and Standby
Power Systems. 8.3.7 requires storage batteries,
including electrolyte levels or battery voltage,
used in connection with systems shall be
inspected weekly and maintained in full
compliance with manufacturer's specifications.
8.3.7.2 states defective batteries shall be repaired
or replaced immediately upon discovery of
defects. Chapter 6.5.4.2 of NFPA 99 requires a
written record of inspection, performance,
exercising period, and repairs shall be regularly
maintained and available for inspection by the
authority having jurisdiction. This deficient
practice could affect all residents, staff and
visitors.
Findings include:
Based on review of the weekly generator
inspection reports on 10/08/19 between 9:15 a.m.
and 11:30 a.m. with the former Maintenance
supervisor was re-educated on
proper timeliness and log
completion. This log is to be kept
with all other logs in the
administrators file.
The administrator shall be
responsible for supervising the
maintenance department in
performing their responsible do
this for the next 12 months.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 20 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
Supervisor and Maintenance
Supervisor-in-training present, there was no
weekly generator testing documentation available
since August 28, 2019. Based on interview at the
time of record review, the former Maintenance
Supervisor said weekly generator testing
documentation since August 28, 2019 could not
be found and was not available for review.
3.1-19(b)
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
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
K 0920
SS=E
Bldg. 01
Based on observation and interview, the facility K 0920 Hillside Manor shall not allow any 11/07/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 21 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
failed to ensure power strips and multiplug
adapters were not used as a substitute for fixed
wiring in 2 of 26 resident rooms, and two staff
areas. LSC 19.5.1.1 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. NFPA 70, Article 400-8
requires, unless specifically permitted, flexible
cords and cables shall not be used as a substitute
for fixed wiring of a structure. This deficient
practice could affect at least 3 resident as well as
staff and visitors.
Findings include:
Based on observations on 10/08/19 between 11:30
a.m. and 1:00 p.m. during a tour of the facility with
the former Maintenance Supervisor and the
current Maintenance Supervisor-in-training, the
following was noted:
a. There was a large refrigerator plugged into a
power strip in the lower level employee breakroom
b. There were two small refrigerators plugged into
a power strip in the north Nurses' Station Med
Room
c. Resident room 22 had a phone charger plugged
into a multi plug adapter
d. Resident room 24 had a lamp plugged into a
multi plug adapter
Based on interview at the time of each
observation, the former Maintenance Supervisor
acknowledged the use of power strips and multi
plug adapters in the previously mentioned
resident rooms and staff locations and said he
was not aware of their existence in the facility.
3.1-19(b)
power cord or extension cord or
multi plug adapters in the patient
care vicinity other than for
removable electrical equipment.
Minimal resident risk was exposed
by two multi plug adapters
powering a cell phone and a lamp.
Resident risk was greater by the
use of power strips power into
small refrigerators, although
protected with a 15 amp breaker.
The residents and their families
will be reminded during the
residence plan of care meetings
that take place quarterly. They will
be asked not to bring any power
strips or multi plug adapters into
the facility.
Equally, Each of the 40+
employees will be single purpose
educated on power strips and
adapters not being allowed in the
building. The nursing staff and the
maintenance supervisor shall
maintain a vigilance for strips,
extension cords, or multi plug
adapters.
, Each of the 40+ employees will
be single purpose educated on
power strips and adapters not
being allowed in the building. The
nursing staff and the maintenance
supervisor shall maintain a
vigilance for strips, extension
cords, or multi plug adapters.
The maintenance supervisor, with
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 22 of 23
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
10/29/2019PRINTED:
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
WASHINGTON, IN 47501
155708 10/08/2019
HILLSIDE MANOR NURSING HOME
1109 E NATIONAL HIGHWAY
01
help from the nursing staff, shall
be responsible for the complete
omission of any strips, extension
cords, or multi-plug adapters. He
shall monitor such weekly
throughout the building, remove
and resolve any placed an error
and report such to the staff and
administration to maintain a watch
for the next 12 months.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GFZK21 Facility ID: 000303 If continuation sheet Page 23 of 23