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Based on observation and interview, the facility failed to ensure 1 of 2 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 19.3.6.1, Exception #6: Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met: (a) The space and the corridor onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4. (b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur. (c) The space does not obstruct access to required exits.
This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on observation on 11/12/14 at 12:40 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, the personal laundry room was open to the corridor. Exception #6 requirement (a) of LSC 19.3.6.1 was not met as follows: The personal laundry room was not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Director of Operations, C.O.O., and the Facilities Manager at the time of observation.

3-1.19(b)

Based on observation and interview, the facility failed to ensure 1 of 3 hazardous area room doors, such as a room over 50 square feet containing combustible material, was equipped with a self closing device on the door. This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on observation on 11/12/14 at 12:59 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer, and the Facilities Manager, the Supply Room, a hazardous area room over 50 square feet containing a large amount of combustible material such as cardboard boxes, paper, plastic, and other items, was not provided with a self closing device on the door. This was acknowledged by the Director of Operations at the time of observation.

Based on record review and interview, the facility failed to provide a complete written fire safety plan for the protection of 15 of 15 residents to accurately address all life safety systems, such as, the transmission of the fire alarm to the fire department/monitoring company, the evacuation of the smoke compartment and the use of fire extinguishers in the facility thus addressing all items required by NFPA 101, 2000 edition, Section 19.7.2.2. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all occupants in the event of an emergency.

Findings include:

Based on a review of the Fire and Explosion Plan section of the Emergency Preparedness Plan on 11/12/14 at 10:05 a.m. with the Director of Operations present, the Fire Plan did not address the transmission of the fire alarm to the fire department/monitoring company, the evacuation of the smoke compartment, and the use of fire extinguishers used in the facility. Based on interview at the time of record review, the Director of Operations acknowledged the Fire Plan was not a complete and accurate plan.

Based on record review and interview, the facility failed to ensure each documented fire drill included complete documentation of the transmission of a fire alarm signal to the monitoring company/fire department for 12 of 13 fire drills. LSC 19.7.1.2 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 occupants on the second floor of the facility.

Findings include:

Based on review of the facility's fire drills on 11/12/14 at 11:10 a.m. with the Director of Operations and Chief Operating Officer (C.O.O.) present, all fire drills (except one - 06/17/14), were not documented to show the fire department/monitoring company received the transmission of the fire alarm. The Director of Operations said the fire drills were silent drills on the second floor where client sleeping rooms were located, but the alarms did ring in all other portions of the facility. The C.O.O. indicated the fire alarms were not sounded on the second floor because it might upset many of the clients.

Based on observation and interview, the facility failed to properly maintain 1 of 1 fire alarm systems in accordance with NFPA 72. NFPA 72, 3-8.1 allows fire alarm system components to share control equipment or operate as stand alone systems, but in any case, they shall be arranged to function as a single system. NFPA 72, 1-5.4.6 requires trouble signals to be located in an area where it is likely to be heard. NFPA 72, 1-5.4.4 requires fire alarms, supervisory signals, and trouble signals to be distinctive and descriptively annunciated. NFPA 72, 5-5.3.2.1.6.1 requires the following: A DACT (Digital Alarm Communicator Transmitter) shall employ one of the following combinations of transmission channels:
(1) Two telephone lines (numbers)
(2) One telephone line (number) and one cellular telephone connection
(3) One telephone line (number) and a one way radio system
(4) One telephone line (number) equipped with a derived local channel
(5) One telephone line (number) and a one way private radio alarm system
(6) One telephone line (number) and a private microwave radio system
(7) One telephone line (number) and a two way RF multiplex system
(8) A single integrated services digital network (ISDN) telephone line using a terminal adapter specifically listed for supervising station fire alarm service, where the path between the transmitter and the switched telephone network serving central office is monitored for integrity so the occurrence of an adverse condition in the path shall be annunciated at the supervising station within 200 seconds. This deficient practice could affect all occupants in the facility.

Findings include:

A. Based on observation on 11/12/14 at 12:20 p.m. with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, there was only one telephone line available for the automatic dialer. Based on interview at the time of observation, it was acknowledged by the Director of Operations, the C.O.O., and the Facilities Manager there was only one telephone line available for the automatic transmission of the fire alarm signal with no other secondary back up in place.

B. Based on observations on 11/12/14 between 12:00 p.m. and 1:15 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, the main Fire Alarm Control Panel (FACP) and the fire alarm communication panel (dialer) were both located in the first floor Mechanical Room. When the Digital Alarm Communicator Transmitter (DACT) was placed in trouble from phone line failure at 12:20 p.m., the DACT did not actuate a local audio trouble signal, furthermore, the DACT did not activate a trouble signal at either FACP annunciator panel located at the front entrance desk and the second floor nurses' station. Based on interview at 1:00 p.m., the Facilities Manager acknowledged the phone line failure did not sound a trouble signal at the FACP or to the fire alarm annunciator panels at the front entrance desk or second floor nurses' station, furthermore, when the Facilities Manager called the fire alarm monitoring company he was told they did not receive a trouble for a phone line failure.

Based on observation and interview, the facility failed to ensure 3 of 52 smoke detectors were not installed where air flow would adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on observations on 11/12/14 between 12:00 p.m. and 1:15 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, the following was noted:
1. There was a ceiling mounted smoke detector within two feet of an air supply vent in the Client Lounge.
2. There was a ceiling mounted smoke detector within one foot of an air supply vent in the corridor outside room 222.
3. There was a ceiling mounted smoke detector within two feet of an air supply vent in the north Staff Office.

This was acknowledged by the Director of Operations, the C.O.O., and the Facilities Manager at the time of each observation.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic sprinkler piping system was inspected every five years as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. Section 10-2.2, Obstruction Prevention, states systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on review of sprinkler system inspection reports on 11/12/14 at 11:20 a.m. with the Director of Operations present, there was no documentation to show the sprinkler system had ever had an internal pipe inspection. Based on an interview at the time of record review, the Director of Operations contacted the sprinkler system inspection company and said there has never been an internal pipe inspection conducted on the partial sprinkler system.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 sprinkler system's gauge was replaced or recalibrated within the past 5 years. NFPA 101 Section 9.7.5 refers to NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 2-3.2 requires gauges to be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on review of sprinkler system inspection reports on 11/12/14 at 11:20 a.m. with the Director of Operations present, there was no documentation to show the sprinkler system gauge had ever been replaced or recalibrated. Based on observation during a tour of the facility with the Director of Operations, the Chief Operating Officer, and the Facilities Manager, it was determined the pressure gauge on the sprinkler system riser had never been replaced. During an interview at the time of observation, the Director of Operations acknowledged the the pressure gauge of the sprinkler system riser had never been replaced.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all occupants in the facility .

Findings include:

Based on observations on 11/12/14 between 12:00 p.m. and 1:15 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, there was no remote alarm annunciator for the emergency generator in a location readily observed by operating personnel at a regular work station such as a nurses' station. This was verified by the Director of Operations, the C.O.O., and the Facilities Manager at the time of observation. Furthermore, there was a remote alarm annunciator for the emergency generator observed at the front entrance desk, however, the C.O.O. said the front entrance desk was not a continuously monitored location.

Based on record review and interview, the facility failed to provide a written policy for the protection of 15 of 15 residents containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all occupants in the facility.

Findings include:

Based on review of the Emergency Preparedness Plan on 11/12/14 at 11:45 a.m. with the Director of Operations present, the facility did not have available a written policy and procedure for an impaired sprinkler system. The facility did have a policy called Interim Life Safety Measures, but it did not address issues required in a Fire Watch Policy such as: Notifying the Indiana State Department of Health (ISDH) and the local Fire Department when the system is out of service for 4 hours or more within a 24 hour time period, phone numbers for the ISDH and local Fire Department, 15 minute walk through of entire facility by the fire watch person, and the only duty the fire watch person shall have will be the fire watch, to name a few items. During an interview at the exit conference, the C.O.O. confirmed the facility did not have a Fire Watch Policy for an impaired sprinkler system.

Based on record review and interview, the facility failed to provide a written policy for the protection of 15 of 15 residents containing procedures to be followed in the event the fire alarm system has to be placed out of services for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all occupants in the facility.

Findings include:

Based on review of the Emergency Preparedness Plan on 11/12/14 at 11:45 a.m. with the Director of Operations present, the facility did not have available a written policy and procedure for an impaired sprinkler system. The facility did have a policy called Interim Life Safety Measures, but it did not address issues required in a Fire Watch Policy such as: Notifying the Indiana State Department of Health (ISDH) and the local Fire Department when the system is out of service for 4 hours or more within a 24 hour time period, phone numbers for the ISDH and local Fire Department, 15 minute walk through of entire facility by the fire watch person, and the only duty the fire watch person shall have will be the fire watch, to name a few items. During an interview at the exit conference, the C.O.O. confirmed the facility did not have a Fire Watch Policy for an impaired sprinkler system.

Based on observation and interview, the facility failed to ensure 1 of 2 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 19.3.6.1, Exception #6: Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met: (a) The space and the corridor onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4. (b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur. (c) The space does not obstruct access to required exits.
This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on observation on 11/12/14 at 12:40 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, the personal laundry room was open to the corridor. Exception #6 requirement (a) of LSC 19.3.6.1 was not met as follows: The personal laundry room was not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Director of Operations, C.O.O., and the Facilities Manager at the time of observation.

3-1.19(b)

Based on observation and interview, the facility failed to ensure 1 of 3 hazardous area room doors, such as a room over 50 square feet containing combustible material, was equipped with a self closing device on the door. This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on observation on 11/12/14 at 12:59 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer, and the Facilities Manager, the Supply Room, a hazardous area room over 50 square feet containing a large amount of combustible material such as cardboard boxes, paper, plastic, and other items, was not provided with a self closing device on the door. This was acknowledged by the Director of Operations at the time of observation.

Based on record review and interview, the facility failed to provide a complete written fire safety plan for the protection of 15 of 15 residents to accurately address all life safety systems, such as, the transmission of the fire alarm to the fire department/monitoring company, the evacuation of the smoke compartment and the use of fire extinguishers in the facility thus addressing all items required by NFPA 101, 2000 edition, Section 19.7.2.2. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all occupants in the event of an emergency.

Findings include:

Based on a review of the Fire and Explosion Plan section of the Emergency Preparedness Plan on 11/12/14 at 10:05 a.m. with the Director of Operations present, the Fire Plan did not address the transmission of the fire alarm to the fire department/monitoring company, the evacuation of the smoke compartment, and the use of fire extinguishers used in the facility. Based on interview at the time of record review, the Director of Operations acknowledged the Fire Plan was not a complete and accurate plan.

Based on record review and interview, the facility failed to ensure each documented fire drill included complete documentation of the transmission of a fire alarm signal to the monitoring company/fire department for 12 of 13 fire drills. LSC 19.7.1.2 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 occupants on the second floor of the facility.

Findings include:

Based on review of the facility's fire drills on 11/12/14 at 11:10 a.m. with the Director of Operations and Chief Operating Officer (C.O.O.) present, all fire drills (except one - 06/17/14), were not documented to show the fire department/monitoring company received the transmission of the fire alarm. The Director of Operations said the fire drills were silent drills on the second floor where client sleeping rooms were located, but the alarms did ring in all other portions of the facility. The C.O.O. indicated the fire alarms were not sounded on the second floor because it might upset many of the clients.

Based on observation and interview, the facility failed to properly maintain 1 of 1 fire alarm systems in accordance with NFPA 72. NFPA 72, 3-8.1 allows fire alarm system components to share control equipment or operate as stand alone systems, but in any case, they shall be arranged to function as a single system. NFPA 72, 1-5.4.6 requires trouble signals to be located in an area where it is likely to be heard. NFPA 72, 1-5.4.4 requires fire alarms, supervisory signals, and trouble signals to be distinctive and descriptively annunciated. NFPA 72, 5-5.3.2.1.6.1 requires the following: A DACT (Digital Alarm Communicator Transmitter) shall employ one of the following combinations of transmission channels:
(1) Two telephone lines (numbers)
(2) One telephone line (number) and one cellular telephone connection
(3) One telephone line (number) and a one way radio system
(4) One telephone line (number) equipped with a derived local channel
(5) One telephone line (number) and a one way private radio alarm system
(6) One telephone line (number) and a private microwave radio system
(7) One telephone line (number) and a two way RF multiplex system
(8) A single integrated services digital network (ISDN) telephone line using a terminal adapter specifically listed for supervising station fire alarm service, where the path between the transmitter and the switched telephone network serving central office is monitored for integrity so the occurrence of an adverse condition in the path shall be annunciated at the supervising station within 200 seconds. This deficient practice could affect all occupants in the facility.

Findings include:

A. Based on observation on 11/12/14 at 12:20 p.m. with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, there was only one telephone line available for the automatic dialer. Based on interview at the time of observation, it was acknowledged by the Director of Operations, the C.O.O., and the Facilities Manager there was only one telephone line available for the automatic transmission of the fire alarm signal with no other secondary back up in place.

B. Based on observations on 11/12/14 between 12:00 p.m. and 1:15 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, the main Fire Alarm Control Panel (FACP) and the fire alarm communication panel (dialer) were both located in the first floor Mechanical Room. When the Digital Alarm Communicator Transmitter (DACT) was placed in trouble from phone line failure at 12:20 p.m., the DACT did not actuate a local audio trouble signal, furthermore, the DACT did not activate a trouble signal at either FACP annunciator panel located at the front entrance desk and the second floor nurses' station. Based on interview at 1:00 p.m., the Facilities Manager acknowledged the phone line failure did not sound a trouble signal at the FACP or to the fire alarm annunciator panels at the front entrance desk or second floor nurses' station, furthermore, when the Facilities Manager called the fire alarm monitoring company he was told they did not receive a trouble for a phone line failure.

Based on observation and interview, the facility failed to ensure 3 of 52 smoke detectors were not installed where air flow would adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on observations on 11/12/14 between 12:00 p.m. and 1:15 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, the following was noted:
1. There was a ceiling mounted smoke detector within two feet of an air supply vent in the Client Lounge.
2. There was a ceiling mounted smoke detector within one foot of an air supply vent in the corridor outside room 222.
3. There was a ceiling mounted smoke detector within two feet of an air supply vent in the north Staff Office.

This was acknowledged by the Director of Operations, the C.O.O., and the Facilities Manager at the time of each observation.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic sprinkler piping system was inspected every five years as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. Section 10-2.2, Obstruction Prevention, states systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on review of sprinkler system inspection reports on 11/12/14 at 11:20 a.m. with the Director of Operations present, there was no documentation to show the sprinkler system had ever had an internal pipe inspection. Based on an interview at the time of record review, the Director of Operations contacted the sprinkler system inspection company and said there has never been an internal pipe inspection conducted on the partial sprinkler system.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 sprinkler system's gauge was replaced or recalibrated within the past 5 years. NFPA 101 Section 9.7.5 refers to NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 2-3.2 requires gauges to be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all occupants on the second floor of the facility.

Findings include:

Based on review of sprinkler system inspection reports on 11/12/14 at 11:20 a.m. with the Director of Operations present, there was no documentation to show the sprinkler system gauge had ever been replaced or recalibrated. Based on observation during a tour of the facility with the Director of Operations, the Chief Operating Officer, and the Facilities Manager, it was determined the pressure gauge on the sprinkler system riser had never been replaced. During an interview at the time of observation, the Director of Operations acknowledged the the pressure gauge of the sprinkler system riser had never been replaced.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all occupants in the facility .

Findings include:

Based on observations on 11/12/14 between 12:00 p.m. and 1:15 p.m. during a tour of the facility with the Director of Operations, the Chief Operating Officer (C.O.O.), and the Facilities Manager, there was no remote alarm annunciator for the emergency generator in a location readily observed by operating personnel at a regular work station such as a nurses' station. This was verified by the Director of Operations, the C.O.O., and the Facilities Manager at the time of observation. Furthermore, there was a remote alarm annunciator for the emergency generator observed at the front entrance desk, however, the C.O.O. said the front entrance desk was not a continuously monitored location.

Based on record review and interview, the facility failed to provide a written policy for the protection of 15 of 15 residents containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all occupants in the facility.

Findings include:

Based on review of the Emergency Preparedness Plan on 11/12/14 at 11:45 a.m. with the Director of Operations present, the facility did not have available a written policy and procedure for an impaired sprinkler system. The facility did have a policy called Interim Life Safety Measures, but it did not address issues required in a Fire Watch Policy such as: Notifying the Indiana State Department of Health (ISDH) and the local Fire Department when the system is out of service for 4 hours or more within a 24 hour time period, phone numbers for the ISDH and local Fire Department, 15 minute walk through of entire facility by the fire watch person, and the only duty the fire watch person shall have will be the fire watch, to name a few items. During an interview at the exit conference, the C.O.O. confirmed the facility did not have a Fire Watch Policy for an impaired sprinkler system.

Based on record review and interview, the facility failed to provide a written policy for the protection of 15 of 15 residents containing procedures to be followed in the event the fire alarm system has to be placed out of services for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all occupants in the facility.

Findings include:

Based on review of the Emergency Preparedness Plan on 11/12/14 at 11:45 a.m. with the Director of Operations present, the facility did not have available a written policy and procedure for an impaired sprinkler system. The facility did have a policy called Interim Life Safety Measures, but it did not address issues required in a Fire Watch Policy such as: Notifying the Indiana State Department of Health (ISDH) and the local Fire Department when the system is out of service for 4 hours or more within a 24 hour time period, phone numbers for the ISDH and local Fire Department, 15 minute walk through of entire facility by the fire watch person, and the only duty the fire watch person shall have will be the fire watch, to name a few items. During an interview at the exit conference, the C.O.O. confirmed the facility did not have a Fire Watch Policy for an impaired sprinkler system.