E 0000 E 0006 07/01/2019 12:00:00Am

PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING -- COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Bldg. -- An Emergency Preparedness Survey was E 0000 It is the intent of this Facility to conducted by the Indiana State Department of develop an Emergency Health in accordance with 42 CFR 483.73. Preparedness Manual which will meet the requirements for Survey Date: 06/03/19 Medicare and Medicaid, which is required for Participating Facility Number: 000158 Providers. Provider Number: 155255 AIM Number: 100291490

At this Emergency Preparedness survey, Woodview A Waters Community was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73. The facility has a capacity of 128 and had a census of 64 at the time of this survey.

The requirement at 42 CFR, Subpart 483.73 is NOT MET as evidenced by:

Quality Review on 06/07/19

E 0006 SS=C Bldg. -- Based on record review and interview, the facility E 0006 It is the intent of this Facility to 07/01/2019 12:00:00AM failed to maintain an emergency preparedness develop an Emergency plan that was (1) based on and includes a Preparedness Manual which will documented, facility-based and community-based meet the requirements for risk assessment, utilizing an all-hazards approach, Medicare and Medicaid, which is including missing residents and (2) included required for Participating strategies for addressing emergency events Providers. identified by the risk assessment in accordance with 42 CFR 483.73(a) (1) and 42 CFR 483.73(a) (2). All residents have the potential to This deficient practice could affect all occupants. be affected by this practice, and it is the intent of the facility to

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

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. ______FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 1 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING -- COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

2. The risk assessment identifies strategies for addressing emergency events including the management of the consequences of power failures, natural disasters, and other emergencies that would affect resident care and safety.

The Facility Administrator/designee has reviewed and signed off on the EPM and will review Annually and as needed for changes or updated.

E 0037 SS=F Bldg. -- Based on record review and interview, the facility E 0037 It is the intent of this facility to 07/01/2019 12:00:00AM failed to ensure the emergency preparedness provide initial training in training and testing program includes a training emergency preparedness using program. The LTC facility must do all of the policies and procedures to all new following: (i) Initial training in emergency and existing staff. Employees will preparedness policies and procedures to all new be trained and demonstrate their

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 2 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING -- COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Based on record review with the Maintenance Director on 06/03/19 at 11:39 a.m., there was no All residents have the potential to documentation of a community based annual be affected by this practice, and it exercise nor documentation of an additional is the intent of the facility to annual exercise within the last year. Based on correct any issues that need to be interview at the time of records review, the corrected concerning this tag. Maintenance Director stated no annual exercises were conducted since he was hired in April 2019 and could not find documentation to show two Employees will be trained and exercises were conducted with in the last year. demonstrate their knowledge of emergency procedures. The facility will maintain documentation of the training and demonstrate staff knowledge of emergency procedures. Both Community based and annual exercise will be conducted prior to expected completed date. And documentation will be maintained by the Facility.

Vice President of Operations will ensure that Training in emergency preparedness is done to include emergency procedures and demonstrate staff knowledge at both

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 3 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING -- COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE E 0039 SS=F Bldg. -- Based on record review and interview, the facility E 0039 It is the intent of this facility to 07/01/2019 12:00:00AM failed to conduct exercises to test the emergency provide initial training in plan at least annually. The LTC facility must do emergency preparedness using all of the following: (i) participate in a full-scale policies and procedures to all new exercise that is community-based or when a and existing staff. Employees will community-based exercise is not accessible, an be trained and demonstrate their individual, facility-based. If the LTC facility knowledge of emergency experiences an actual natural or man-made procedures. The facility will emergency that requires activation of the maintain documentation of the emergency plan, the LTC facility is exempt from training and demonstrate staff engaging in a community-based or individual, knowledge of emergency facility-based full-scale exercise for 1 year procedures. Both Community following the onset of the actual event; (ii) based and annual exercise will be conduct an additional exercise that may include, conducted prior to expected but is not limited to the following: (A) a second completed date. And full-scale exercise that is community-based or documentation will be maintained individual, facility-based. (B) a tabletop exercise by the Facility. that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem All residents have the potential to statements, directed messages, or prepared be affected by this practice, and it questions designed to challenge an emergency is the intent of the facility to plan. (iii) Analyze the LTC facility's response to correct any issues that need to be and maintain documentation of all drills, tabletop corrected concerning this tag. exercises, and emergency events, and revise the facility's emergency plan, as needed in accordance with 42 CFR 483.73(d)(2). This deficient practice Employees will be trained and could affect all occupants. demonstrate their knowledge of emergency procedures. The Findings include: facility will maintain documentation of the training and Based on record review with the Maintenance demonstrate staff knowledge of Director on 06/03/19 at 11:12 a.m., there was no emergency procedures. Both documentation of a community based annual Community based and annual exercise nor documentation of an additional exercise will be conducted prior to annual exercise within the last year. Based on expected completed date. And interview at the time of records review, the documentation will be maintained

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 4 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING -- COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

E 0041 SS=C Bldg. -- Based on record review and interview, the facility E 0041 It is the intent of the facility to 07/01/2019 12:00:00AM failed to implement the emergency power system maintain the emergency power inspection, testing, and maintenance requirements generator and to ensure that found in the Health Care Facilities Code, NFPA Monthly load test are completed, 110, and Life Safety Code in accordance with 42 Weekly checks are done the fuel CFR 483.73(e)(2). This deficient practice could quality test has been done. affect all occupants.

Findings include: All residents have the potential to be affected by this practice, and it Based on record review with the Maintenance is the intent of the facility to Director 06/03/19 at 11:10 a.m., the emergency correct any issues that need to be power generator was not properly maintained due corrected concerning this tag. to the following issues: a) Missing monthly load test Emergency Power Generator has b) Missing weekly checks. had the Monthly load test done, c) No load bank test. and the weekly checks are being d) No fuel quality test. done , and the fuel quality test has e) No battery powered light at the generator. been taken and sent off for testing. Based on interview at the time of record review, the Maintenance Director agreed there were The 57 rooms that have battery missing inspection and testing documentation. operated smoke detectors have had batteries replaced, and these

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 5 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING -- COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

The Maintenance Man/Designee will be responsible for auditing the batteries to ensure they are in good working order. The battery operated smoke detectors must remain at a 100% compliant.

K 0000

Bldg. 01 A Life Safety Code Recertification and State K 0000 It is the intent of this Facility to Licensure Survey was conducted by the Indiana develop an Emergency State Department of Health in accordance with 42 Preparedness Manual which will CFR 483.90(a). meet the requirements for Medicare and Medicaid, which is Survey Date: 06/03/19 required for Participating Providers. Facility Number: 000158 Provider Number: 155255 AIM Number: 100291490

At this Life Safety Code survey, Woodview A Waters Community was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.

This one story facility was determined to be of Type V (111) construction and was fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors, areas open to the corridors, and seven resident rooms on the Rehabilitation Hall. The remaining 57 resident rooms had battery operated smoke detectors. The

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 6 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

All areas where the residents have customary access were sprinklered. All areas providing facility services were sprinklered.

Quality Review on 06/07/19

K 0232 NFPA 101 SS=E Aisle, Corridor, or Ramp Width Bldg. 01 Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5 Based on observation and interview, the facility K 0232 It is the intention of this building to 07/01/2019 12:00:00AM failed to meet the clear width requirement for 1 of 8 maintain all halls to be clear of of corridors or met an exception per 19.2.3.4(5). LSC any obstructions to meet the 19.2.3.4(5) states where the corridor width is at requirements set down. least 8 feet, projections into the required width shall be permitted for fixed furniture, provided that All residents have the potential to all of the following conditions are met: be affected by this practice, and it (a) The fixed furniture is securely attached to the is the intent of the facility to floor or to the wall. correct any issues that need to be (b) The fixed furniture does not reduce the clear corrected concerning this tag. unobstructed corridor width to less than six feet, except as permitted by 19.2.3.4(2). The objects that were in the rehab (c) The fixed furniture is located only on one side corridor have been removed. of the corridor. (d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 square The maintenance man/ designee feet. will be responsible to audit that (e) The fixed furniture groupings addressed in there are no objects blocking any 19.2.3.4(5) (d) are separated from each other by a of the corridors throughout the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 7 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on observation during a tour of the facility with the Maintenance Director on 06/03/19 at 1:13 p.m., the Rehab exit corridor measured eight feet in clear width. There were two chairs in the hall that extended about two feet into the corridor and were not affixed to the floor or to the wall when tested. Based on interview at the time of the observations, the Maintenance Director acknowledged the furniture in the aforementioned corridor was not affixed to the floor or to the wall.

3.1-19(b)

K 0293 NFPA 101 SS=E Exit Signage Bldg. 01 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 8 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include: The maintenance man/designee will ensure that the No Exit sign Based on observation during a tour of the facility remains on the for as long as the with the Maintenance Director on 06/03/19 at 1:52 door is not being used as an exit. p.m., in the 200 hall the door by the nurses' station led to the resident smoking area outside. The door to the resident smoking area was not posted with a NO EXIT sign. Based on interview at the time of the observations, the Maintenance Director stated the door to the resident smoking area is not an exit and acknowledged the door did not have a NO EXIT sign posted.

3.1-19(b)

K 0300 NFPA 101 SS=F Protection - Other Bldg. 01 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 9 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Based on record review, interview and K 0300 It is the intent of the facility to 07/01/2019 12:00:00AM observation; the facility failed to ensure maintain documentation for the documentation for the preventative maintenance preventative maintenance to be of 57 of 57 battery operated smoke alarms in done in the building. resident rooms was complete. NFPA 101 in 4.6.12.3 states existing life safety features obvious All residents have the potential to to the public, if not required by the Code, shall be be affected by this practice, and it maintained. NFPA 72, 29.10 Maintenance and is the intent of the facility to Tests. Fire-warning equipment shall be maintained correct any issues that need to be and tested in accordance with the manufacturer's corrected concerning this tag. published instructions and per the requirements of Chapter 14. NFPA 72, 14.2.1.1.1 Inspection, The Manufactures documentation testing, and maintenance programs shall satisfy has been located and the batteries the requirements of this Code and conform to the have been changed out and will be equipment manufacturer's published instructions. checked and changed out This deficient practice could affect all residents, quarterly and the cleaning will be staff, and visitors. documented with the preventative maintenance records Findings include: The maintenance man/designee Based on review of the smoke detectors reports will be responsible for checking with the Maintenance Director on 06/03/19 at the batteries monthly and cleaning 10:15 a.m., the itemized list of resident room the fire detectors and then battery operated smoke alarms did show testing Quarterly the batteries will be for functionality but did not indicate if any changed out. And the cleaning was performed. Furthermore, the maintenance man/designee will be manufacture's documentation was not available responsible to record and for review in order to determine the frequency of document that all smoke alarms testing and cleaning. Based on interview at the are in good working order. time of review, the Maintenance Director did not know if the detectors have been cleaned according to manufactures recommendations.

3.1-19(b)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 10 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) Based on observation and interview, the facility K 0321 It is the intent of this building to 07/01/2019 12:00:00AM failed to ensure the corridor doors to 2 of 2 rooms maintain fire barriers in this with combustible storage greater than 50 square building so that the residents feet and 1 of 1 soil linen storage areas were remain safe. provided with a self-closing door which would

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 11 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Based on observations during a tour of the facility The two rooms on 200 hall 201 with the Maintenance Director on 06/03/19 and 204 have had self closer's between 1:30 p.m. and 2:00 p.m., the following was installed on the doors and the observed: latching has been checked to a) Rooms 201 and 204 contained over 30 boxes of ensure the doors latch when paper and supplies, was greater than 50 square closing. feet, and did not have self-closing doors. b) The 200 hall shower room contained soiled The maintenance man/designee linen and trash, the door was self-closing but did will check the doors weekly to not have the correct force to latch the door. ensure the doors are automatically Based on interview at the time of observation, the closing and that the latch is Maintenance Director agreed rooms were used as secure. These doors will be storage for boxes, were larger than 50 square feet, maintained at 100% compliance. and the doors to these rooms were not self-closing and the shower room door was not self-latching.

3.1-19(b)

K 0324 NFPA 101 SS=C Cooking Facilities Bldg. 01 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 12 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 Based on record review, observation and K 0324 It is the intent of this facility to see 07/01/2019 12:00:00AM interview; the facility failed to ensure 1 of 1 that all annual and semiannually kitchen fire suppression system was inspected inspections are done as required. semiannually. NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of All residents have the potential to Commercial Cooking Operations, Section 11.2.1 be affected by this practice, and it states Maintenance of the fire-extinguishing is the intent of the facility to systems and listed exhaust hoods containing a correct any issues that need to be constant or fire-activated water system that is corrected concerning this tag. listed to extinguish a fire in the grease removal devices. Hood exhaust plenums, and the exhaust After the surveyor left the ducts shall be made by properly trained, qualified, inspection for 6 month earlier from and certified person(s) acceptable to the authority 3/11/19 date was received from having jurisdiction at lease every six months. the inspection company for the This deficient practice could affect staff and 30 Suppression System. residents in the dining room. Extinguisher Co. No.1 is the inspection company and the Findings include: earlier inspection was done on 8/16/2018. Based on records review with the Maintenance Director on 06/03/19 at 10:30 a.m., there was The maintenance man will be documentation of a kitchen exhaust system responsible for maintaining the inspection dated 03/11/19 but no documentation documents from the inspections of of semiannual kitchen exhaust system inspection the different company's used for six months prior was available for review. Based inspections of the building. on interview at the time of record review, the Maintenance Director stated he could only find The maintenance man will be one kitchen exhaust system inspection at the time responsible for maintaining the of survey. logs of inspections needed and to record after they are done.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 13 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

K 0345 NFPA 101 SS=F Fire Alarm System - Testing and Bldg. 01 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 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 K 0345 It is the intent of the facility to 07/01/2019 12:00:00AM failed to maintain 1 of 1 fire alarm systems in maintain the alarm system as accordance with NFPA 72, as required by LSC 101 required. Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by All residents have the potential to 14.3.2, visual inspections shall be performed in be affected by this practice, and it accordance with the schedules in Table 14.3.1, or is the intent of the facility to more often if required by the authority having correct any issues that need to be jurisdiction. Table 14.3.1 states that the following corrected concerning this tag. must be visually inspected semi-annually: a. Control unit trouble signals The contract company was out b. Remote annunciators to inspect the fire alarm system c. Initiating devices (e.g. duct detectors, manual and found the alarm system to be fire alarm boxes, heat detectors, smoke detectors, in good working order 4/2/2019. etc.) The semi-annual inspection will be d. Notification appliances done by the maintenance man at e. Magnetic hold-open devices the semi-annual date which should This deficient practice could affect all building be in October 2019. occupants. The maintenance man will be Findings include: responsible to insure the annual and semi-annual inspections are During record review with the Maintenance done and that the documents are

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 14 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

3.1-19(b)

K 0351 NFPA 101 SS=E Sprinkler System - Installation Bldg. 01 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) Based on observation and interview, the facility K 0351 It is the intent of this facility to 07/01/2019 12:00:00AM failed to maintain the ceiling construction in 3 of 8 maintain the sprinkler systems in smoke compartments in accordance with NFPA the facility to include the sprinkler 13, Standard for the Installation of Sprinkler escutcheons. Systems. NFPA 13, 2010 edition, Section 6.2.7.1 states plates, escutcheons, or other devices used All residents have the potential to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 15 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

K 0353 NFPA 101 SS=F Sprinkler System - Maintenance and Testing Bldg. 01 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 ______Provide in REMARKS information on coverage for any non-required or partial

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 16 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Based on records review of the facility's sprinkler vendor's "Inspection Report" documentation dated 03/07/19 with Maintenance Director on 06/03/19 at 10:18 a.m., the report identified six deficient items; a) Dry system pressure switch bell did not respond to fire panel. b) Control valve and antifreeze tamper switch did not respond to fire panel. c) No Hydraulic placard in place. d) Air compressor needs replaced with a permanent air compressor. e) No low air installed on dry system.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 17 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

3.1-19(b)

2. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3. NFPA 25, 2011 Edition, 14.2.1 states except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficient practice could affect all occupants.

Findings include:

Based on records review with the Maintenance Director on 6/03/19 at 10:33 a.m., no internal inspection of sprinkler piping was available for review. The facility's sprinkler vendor's "Inspection Report" documentation dated 03/07/19 did state last internal inspection was conduct in 2014 and was due in 2019. Based on interview at the time of record review, the Maintenance Director stated the internal inspection documentation could not be found and has not yet scheduled an inspection.

3.1-19(b)

3 . Based on record review and interview, the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 18 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on records review with the Maintenance Director on 6/03/19 at 10:03 a.m., there was no documentation of a weekly inspection of the dry system gauges, no monthly inspection of the wet pipe sprinkler system's gauges, and no monthly control valve inspections available for review. During an interview at the time of records review, the Maintenance Director stated no gauge and valve inspection were conducted since he was hired in April 2019 and could not find documentation to show any other gauge and valve inspections.

3.1-19(b)

K 0363 NFPA 101 SS=E Corridor - Doors Bldg. 01 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 19 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. 1. Based on observation and interview, the K 0363 It is the intent of this facility to 07/01/2019 12:00:00AM facility failed to ensure 7 of 10 resident room maintain corridor doors both

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 20 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Based on observation with the Maintenance Director during a tour of the facility on 06/03/19 at 12:10 p.m., the corridor door to resident room 32 did not latch into the frame when tested due to door damage. Based on interview at the time of observation, the Maintenance Director stated the corridor door would latch into the door frame because the door was broken but a new door was on order.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 21 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

K 0372 NFPA 101 SS=E Subdivision of Building Spaces - Smoke Bldg. 01 Barrie Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. Based on observation and interview, the facility K 0372 It is the intent of this facility to 07/01/2019 12:00:00AM failed to ensure the penetrations caused by the keep all the smoke barriers intact passage of wire and/or conduit through 1 of 1 within the building. ceiling smoke barriers were protected to maintain the smoke resistance of each smoke barrier. LSC All residents have the potential to Section 19.3.7.5 requires smoke barriers to be be affected by this practice, and it constructed in accordance with LSC Section 8.5 is the intent of the facility to and shall have a minimum ½ hour fire resistive correct any issues that need to be rating. LSC Section 8.5.2.1 requires smoke barriers corrected concerning this tag. to be continuous from an outside wall to an outside wall, from a floor to a floor, or from a The penetrations that were found smoke barrier to a smoke barrier, or by use of a in the laundry area have been combination thereof. 8.5.6.2 requires penetrations addressed the hall way with the for cables, cable trays, conduits, pipes, tubes, hole that was taped over has been vents, wires, and similar items to accommodate fixed, and also the 6"x 4" patched electrical, mechanical, plumbing, and area has been repaired. communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a The maintenance man will be smoke barrier, or through the ceiling membrane of responsible for repairing any the roof/ceiling of a smoke barrier assembly, shall breach in the smoke barrier that be protected by a system or material capable of should be found or after work is

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 22 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

3.1-19(b)

K 0374 NFPA 101 SS=E Subdivision of Building Spaces - Smoke Bldg. 01 Barrie Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 23 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include: A contract door company has been called in to repair the smoke Based on observation with the Maintenance barrier doors parts have been Director during a tour of the facility on 06/03/19 at ordered and installed as soon as 12:00 p.m., the set of smoke barrier doors to north parts come in. hall would not fully close due to the coordinating device on the door frame not correctly working The maintenance man will be and holding the doors open. Based on interview responsible to ensure that the during the time of observation, the Maintenance smoke barrier doors are in good Director stated the coordinating device needed working order and he is to repair and was holding the doors open. maintain the documents of where he has done routine checks on the 3.1-19(b) doors throughout the month.

K 0511 NFPA 101 SS=E Utilities - Gas and Electric Bldg. 01 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 1. Based on observation and interview, the K 0511 It is the intent of this facility to 07/01/2019 12:00:00AM facility failed to ensure 4 of 4 electrical junction ensure that all electrical junction boxes or devices were maintained in a safe boxes or devices are maintained in

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 24 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

3.1-19(b)

2. Based on observation and interview, the facility failed to ensure 2 of 2 electrical panels in the corridors were secured from non-authorized personnel. NFPA 70, 2011 edition states 230.62 Energized parts of service equipment shall be enclosed as specified in 230.62(A) or guarded as specified in 230.62(B). (A) Enclosed. Energized parts shall be enclosed so that they will not be exposed to accidental contact or shall be guarded as in 230.62(B).

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 25 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on observations during a tour of the facility with the Maintenance Director on 06/03/19 between 12:20 p.m. and 2:00 p.m., the electrical panels in the North hall and Rehab hall were unlocked when tested. The panel included breakers to the lights, emergency lighting, and outlets in the service hall. Based on interview at the time of observation, the Maintenance Director stated the electrical panels will need to be locked.

3.1-19(b)

K 0522 NFPA 101 SS=E HVAC - Any Heating Device Bldg. 01 HVAC - Any Heating Device Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also: * is chimney or vent connected. * takes air for combustion from outside. * provides for a combustion system separate from occupied area atmosphere. 19.5.2.2 Based on observation and interview, the facility K 0522 It is the intent of this facility not to 07/01/2019 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 26 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE failed to ensure 1 of 1 fuel fire heating devices use any electronic devices or fuel complied with LSC 19.5.2. LSC 19.5.2.2 states any fire devices that are not approved heating device, other than a central heating plant, for Nursing Home use. shall be designed and installed so that combustible material cannot be ignited by the device or its appurtenances, and the following All residents have the potential to requirements also shall apply: be affected by this practice, and it (1) If fuel-fired, such heating devices shall comply is the intent of the facility to with the following: correct any issues that need to be (a) They shall be chimney connected or vent corrected concerning this tag. connected. (b) They shall take air for combustion directly The portable heater that was found from the outside. has been removed, and (c) They shall be designed and installed to Maintenance man is aware that provide for complete separation of the no electric heaters or other combustion system from the atmosphere of the heating elements are allowed in occupied area. the building. (2) Any heating device shall have safety features to immediately stop the flow of fuel and shut The maintenance man will make down the equipment in case of either excessive weekly rounds and if unproved temperature or ignition failure. electric devices are found they will This deficient practice could affect 25 residents in be removed immediately. the Hope Springs wing. To goal is to be at 100% Findings include: compliant with not having electric devices that are not approved, Based on observation with Maintenance Director findings will be reviewed at on 06/03/19 at 12:30 p.m., a portable fuel fired monthly QA meetings. heater (a salamander heater) was in the exit hall of the Hope Springs wing. The exit hall did not meet requirements of [(1) a, b, and c] listed above. Based on interview at the time of the observations, the Maintenance Director stated he was unaware there was a fuel fired heater in the exit hall and agreed the exit hall is not designed for fuel fired heaters.

3.1-19(b)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 27 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE K 0712 NFPA 101 SS=C Fire Drills Bldg. 01 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 Based on record review and interview, the facility K 0712 It is the intent of this facility to 07/01/2019 12:00:00AM failed to ensure 3 of 12 fire drills included the ensure that all fire drills are done verification of transmission of the fire alarm signal on all three shifts each quarter as to the monitoring station in fire drills conducted required. between 6:00 a.m. and 9:00 p.m. for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health All residents have the potential to care occupancies shall include the transmission of be affected by this practice, and it a fire alarm signal and simulation of emergency fire is the intent of the facility to conditions. This deficient practice affects all correct any issues that need to be residents in the facility as well as staff and corrected concerning this tag. visitors. The maintenance has been Findings include: in-serviced on how fire drills are to be done with all 3 shifts each Based on records review with the Maintenance quarter and if 3rd shift is done Director on 06/03/19 at 9:34 a.m., the fire drill forms silent the next day the fire signal for third shift drills indicated transmission of must be transmitted to the signal was not tested for the 1st 2nd and 3rd monitoring company the next day quarters of the last year. Based on interview at the time of record review, the Maintenance The maintenance man his Director stated he did not transmit the signal the responsible for keeping all the next day and was unaware the transmission of documentation and making sure signal had to be tested for drills on third shift. the drills are done and transmitted. 3.1-19(b)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 28 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

K 0741 NFPA 101 SS=E Smoking Regulations Bldg. 01 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 1. Based on observation and interview; the K 0741 It is the intent of this facility that 07/01/2019 12:00:00AM facility failed to ensure 2 of 2 smoking areas were all cigarette butts are dis-guarded maintained by disposing cigarette butts in the into approved receptacles provided metal or noncombustible containers with to keep the grounds free from self-closing cover devices. This deficient practice cigarette butts. affect 10 residents in the court yard and staff

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 29 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on observations during a tour of the facility with the Maintenance Director on 06/03/19 at 9:00 a.m. and 1:33 p.m., outside exit 5 (a non-smoking area) smoking was apparent due to there were at least 20 cigarette butts on the ground in the mulch. Based on records review at 3:13 p.m., the written smoking policy stated "smoking will only be allowed in the designated area." Based on interview at the time of observation and records review, the Maintenance Director agreed there

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 30 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

3.1-19(b)

K 0761 SS=E Bldg. 01 Based on observation, records review, and K 0761 It is the intent of this facility that 07/01/2019 12:00:00AM interview; the facility failed to ensure annual doors are annually inspection and inspection and testing of 1 of 1 fire door tested for fire rating and for dividing assemblies were completed in accordance with fire barriers from halls. LSC 19.1.1.4.1.1 communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be All residents have the potential to permitted only in corridors and shall be protected be affected by this practice, and it by approved self-closing fire door assemblies. is the intent of the facility to (See also Section 8.3.) LSC 8.3.3.1 Openings correct any issues that need to be required to have a fire protection rating by Table corrected concerning this tag. 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window A contract door company has assemblies and their accompanying hardware, been called in to repair the smoke including all frames, closing devices, anchorage, barrier doors parts have been and sills in accordance with the requirements of ordered and installed as soon as NFPA 80, Standard for Fire Doors and Other parts come in. Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire The maintenance man will be door assemblies shall be inspected and tested not responsible to ensure that the less than annually, and a written record of the smoke barrier doors are in good inspection shall be signed and kept for inspection working order and he is to by the AHJ. NFPA 80, 5.2.4.1 states fire door maintain the documents of where assemblies shall be visually inspected from both he has done routine checks on the sides to assess the overall condition of door doors throughout the month. assembly. NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 31 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on record review with the Maintenance Director on 06/03/19 at 9:50 a.m., no documentation was available for review to show if the occupancy separation fire door was inspected at least annually according to NFPA 80. Based on observation during the tour at 1:50 p.m. there was a one and a half hour fire rated door assembly in an occupancy separation wall at the end of rehab hall. Based on interview at the time of records review and observation, the Maintenance Director stated he did not know if the occupancy separation door was inspected annually.

3.1-19(b)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 32 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include: All residents have the potential to be affected by this practice, and it Based on observation with Maintenance Director is the intent of the facility to on 06/03/19 at 12:30 p.m., a portable fuel fired correct any issues that need to be space heater (a salamander heater) was stored in corrected concerning this tag. the exit hall of the Hope Springs wing; a residential care wing. Based on interview at the The portable heater that was found time of the observations, the Maintenance has been removed, and Director stated he did not know why a salamander Maintenance man is aware that portable heater was in the building and agreed it no electric heaters or other should not be in the building. heating elements are allowed in the building. 3.1-19(b) The maintenance man will make weekly rounds and if unproved electric devices are found they will be removed immediately.

To goal is to be at 100% compliant with not having electric devices that are not approved, findings will be reviewed at monthly QA meetings.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 33 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE K 0914 NFPA 101 SS=F Electrical Systems - Maintenance and Bldg. 01 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. 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 K 0914 It is the intent of the facility to 07/01/2019 12:00:00AM interview; the facility failed to ensure non-hospital ensure non-hospital grade grade electrical receptacles at 62 of 62 resident electrical receptacles are checked care rooms were tested at least annually. NFPA annually. 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.3 states receptacles not listed as All residents have the potential to hospital-grade, at patient bed locations and in be affected by this practice, and it locations where deep sedation or general is the intent of the facility to anesthesia is administered, shall be tested at correct any issues that need to be intervals not exceeding 12 months. Additionally, corrected concerning this tag. Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each All receptacles have been

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 34 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on observations with the Maintenance Director during a tour of the facility on 06/03/19 from 11:00 a.m. to 3:15 p.m., the facility's 62 resident care rooms/locations contained four to eight electrical receptacles in each resident room. Based on records review at 3:30 p.m. no documentation was available to show electrical receptacles in resident care areas were tested annually. Based on interview at the time of the observation, the Maintenance Director indicated all of the electrical receptacles in the resident care areas were not hospital-grade and also indicated there was no documentation of annual testing per NFPA 99, Receptacle Testing requirements.

3.1-19(b)

K 0918 NFPA 101 SS=F Electrical Systems - Essential Electric Syste Bldg. 01 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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 35 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include: All residents have the potential to be affected by this practice, and it Based on observations during a tour of the facility is the intent of the facility to with the Maintenance Director on 06/03/19 at 1:50 correct any issues that need to be p.m., the generator's annunciator panel was corrected concerning this tag.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 36 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE located at the 200 nurses' station but the 200 hall was empty and no staff were in the hall. This An electrician has been condition would not alert staff if there was a contracted to move the generator malfunction. Based on interview at the annunciator panel to have it visible time of observation, the Maintenance Director at the ICF nursing station that is stated due to census the 200 hall was closed manned at all times. down and the generator's annunciator panel was no longer in a location that was occupied by staff A company has been retained to throughout all shifts. do the annual fuel quality test on the diesel, the diesel sample has 3.1-19(b) been sent off for testing. The maintenance will keep a record of 2. Based on record review and interview, the the testing and order it to be done facility failed to ensure an annual fuel quality test annual. was performed for 1 of 1 facility's diesel powered generator. NFPA 99, Health Care Facilities Code, The maintenance man will be 2012 Edition Section 6.5.4.1.1.2 states Type 2 EES responsible to see that the (Essential Electrical System) generator sets shall generator is ran for no less than be inspected and tested in accordance with 30 minutes each month for a full Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states load, and record that the maintenance shall be performed in accordance inspection, with NFPA 110, Standard for Emergency and performance,exercising period and Standby Power Systems, 2010 Edition, Chapter 8. any repairs for the generator are to NFPA 110, Section 8.3.8 states a fuel quality test be recorded and available for shall be performed at least annually using tests inspection. approved by ASTM standards. This deficient practice could affect all residents. The maintenance man will be responsible for the weekly test Findings include: and to ensure that the documentation is done to ensure Based on record review with the Maintenance recording of information is Director 06/03/19 at 11:10 a.m., no documentation available for inspections of an annual fuel quality test for the diesel generator was available for review. Based on The maintenance man will install interview at the time of records review, the an outside light which will be Maintenance Director stated the facility does battery operated to illuminate the have a diesel generator but was unaware of the outside around the generator at fuel quality testing requirements. night.

3.1-19(b) The maintenance man will be

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 37 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on records review with the Maintenance Director on 06/03/19 at 11:10 a.m., prior to May 2019 no documentation was available for review to show the diesel generator set in service was exercised at least once monthly, for a minimum of 30 minutes. Based on an interview at the time of record review, the Maintenance Director stated he conducted monthly generator load since he was hired in April 2019 but could not find any other documentation to show any other generator load testing.

3.1-19(b)

4. Based on record review and interview, the facility failed to ensure a written record of weekly inspections for the generator was maintained for 28 of 52 weeks. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 38 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on records review with the Maintenance Director on 06/03/19 at 11:10 a.m., prior to May 2019 no documentation was available for review to show the diesel generator sets in service was inspected weekly. Based on an interview at the time of record review, the Maintenance Director stated he conducted weekly generator inspections since he was hired in April 2019 but could not find any other documentation to show any other generator weekly inspections.

3.1-19(b)

5. Based on records review, observation and interview; the facility failed to ensure 1 of 1 emergency task generator was provided with battery backup lights. NFPA 110, 2010 Edition at section 7.3.1 requires the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This deficient practice could affect all residents in the facility.

Findings include:

Based on observation review with the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 39 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

3.1-19(b)

6. Based on record review and interview, the facility failed to exercise 1 of 1 generators annually to meet the requirements of NFPA 110, 2010 Edition, the Standard for Emergency and Standby Powers Systems, Chapter 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under operating temperature conditions and at not less than 30 percent of the EPS (Emergency Power Supply) nameplate kW rating. Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS (Emergency Power Supply System) load and shall be exercised annually with supplemental loads (Load Bank Test) at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. This deficient practice could affect all occupants.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 40 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Findings include:

Based on records review with the Maintenance Director on 06/03/19 at 10:47 a.m., the two available monthly load testes did not record the load percentage for the diesel powered generator and due to the missing load tests the monthly load percentage could not be determined for the year. There was a form from W.W.Willams in April 2019 stating the facility requested a load bank test but the documentation did not show if a load bank was conducted or results of the load bank. Based on interview at the time of record review, the Maintenance Director stated he did not know if the generator met 30% of the load for the year or if a load bank test was conducted.

3.1-19(b)

7. Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test. 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. NFPA 110, 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all residents, as well as staff and visitors in the facility.

Findings include:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 41 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Based on records review with the Maintenance Director on 06/03/19 at 10:47 a.m., the generator log form documented the generator was tested monthly for at least 30 minutes under load however, space for the cool down time was not filled in. Based on interview at the time of record review, the Maintenance Director stated there is a cool down but it was not documented.

3.1-19(b)

K 0920 NFPA 101 SS=E Electrical Equipment - Power Cords and Bldg. 01 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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 42 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

(X4) ID SUMMARY STATEMENT OF DEFICIENCIE ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG DEFICIENCY) DATE Based on observation and interview, it could not K 0920 It is the intent of this facility to not 07/01/2019 12:00:00AM be assured 1 of 1 extension cords, multi plug use any extension cords , multi adapters, or power strips used in patient care plug adapters, or power strips that vicinities met UL 1363A or UL60601-1. NFPA 99, are not Hospital grade. Standard for Health Care Facilities, 2012 edition, defines patient care areas as any portion of a All residents have the potential to health care facility wherein patients are intended be affected by this practice, and it to be examined or treated. Patient care vicinity is is the intent of the facility to defined as a space, within a location intended for correct any issues that need to be the examination and treatment of patients, corrected concerning this tag. extending 6 feet beyond the normal location of the bed, chair, table, treadmill, or other device that Any extension cords, multi plug supports the patient during examination and adapters or power strips that were treatment. A patient care vicinity extends not Hospital Grade were removed. vertically to 7 feet 6 inches above the floor. This deficient practice could affect 10 residents in 5 The maintenance man will be rooms. responsible for checking rooms on his rounds to ensure no Findings include: un-authorized electric devices are being used. Based on observations with the Maintenance Director during a tour of the facility from 11:10 a.m. to 3:10 p.m. on 06/03/19, in rooms 24, 26, 34, 309, 307 it could not be determined if extension cord power strips and medical grade adaptors in use powering medical equipment met 1363A or UL60601-1. Based on interview at the time of observation, the Maintenance Director stated he bought medical grade adaptors that screwed into the wall outlets but could not determine if the adaptors and extension cord power strip met UL 1363A or UL60601-1.

3.1-19(b)

K 0927 NFPA 101 SS=C Gas Equipment - Transfilling Cylinders Bldg. 01 Gas Equipment - Transfilling Cylinders Transfilling of oxygen from one cylinder to another is in accordance with CGA P-2.5,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 43 of 44 PRINTED: 07/08/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-039 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 01 COMPLETED 155255 B. WING 06/03/2019

STREET ADDRESS, CITY, STATE, ZIP COD NAME OF PROVIDER OR SUPPLIER 3420 EAST STATE BLVD WOODVIEW A WATERS COMMUNITY FORT WAYNE, IN 46805

Based on observations during a tour of the facility A sign was placed outside the with the Maintenance Director on 06/03/19 at room where the O2 transferring is 12:17 p.m., the oxygen storage/transfer room did done. I will be the maintenance not contain a sign indicating when transferring of man that will ensure the sign is in oxygen occurs in this location. Based on place during his daily rounds of interview at the time of observation, the the facility. Maintenance Director stated the sign indicating when transferring of oxygen occurs was in his life The maintenance man will ensure safety book and was not readily available for staff there is documentation to note to post when trans-filling oxygen. that the sign is in place on his daily rounds. 3.1-19(b)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3P2C21 Facility ID: 000158 If continuation sheet Page 44 of 44