printed: 10/29/2019 department of health and human ... · (x1) provider/supplier/clia department of...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

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NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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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

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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

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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 of 23

(X6) DATE




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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

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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

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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

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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

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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:





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





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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

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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.

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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

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and testing are readily available.

9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72


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

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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

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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:




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

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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


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

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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

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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.





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(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





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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



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


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

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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)


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


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.





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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


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





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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


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





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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

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Findings include:




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

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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)


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:


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

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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)


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.





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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





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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





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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.


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