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Based on observation, record review and interview; the facility failed to implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code in accordance with 42 CFR 483.73(e)(2).

Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 1 of 1 generator during 1 of the past 12 months. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. Chapter 6-4.4.1.3 of 2012 NFPA 99 requires batteries for on-site generators shall be maintained in accordance with NFPA 110, 2010 Edition, Standard for Emergency and Standby Power Systems. 8.3.7 requires storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8.3.7.2 states defective batteries shall be repaired or replaced immediately upon discovery of defects. Chapter 6.5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on record review on 02/15/2022 between 10:30 a.m. and 1:35 p.m. with the Director of Facilities and General Services Supervisor present, there was no monthly generator load test documentation available for January of 2022. Based on interview at the time of record review, the General Services Supervisor confirmed there was no emergency generator load test documentation for January 2022.

This finding was reviewed with the Accreditation & Quality Improvement Director, Director of Facilities, and General Services Supervisor during the exit conference.

1. Based on observation and interview, the facility failed to ensure 1 of 30 battery powered emergency lighting systems was maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on observations with the Director of Facilities and General Services Supervisor during a tour of the facility from 1:35 p.m. to 2:40 p.m. on 2/15/22, the battery operated light labeled IP-1 located on the left wall right inside the entry door to the Inpatient area failed to illuminate when its respective test button was pushed multiple times. Based on interview at the time of the observation, the General Services Supervisor stated the lights are tested on a monthly basis but agreed the aforementioned battery powered emergency light failed to illuminate when its respective test button was pushed multiple times.

2. Based on record review, observation and interview; the facility failed to document monthly testing for 30 of 30 battery backup lights in accordance with LSC 7.9. Section 7.9.3.1.1 states testing of emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
This deficient practice could affect all residents, staff and visitors if needing to exit the facility.

Findings include:

Based on review of Emergency Lighting documentation for the most recent twelve month period with the Director of Facilities and General Services Supervisor during record review from 10:30 a.m. to 2:40 p.m. on 02/15/22, monthly functional testing documentation for 30 of 30 battery operated emergency lights for January and February 2022 was not available for review. Based on interview at the time of record review, the General Services Supervisor confirmed that 30 second monthly functional test for January and February 2022 was not available for review at the time of the survey.

These findings were reviewed with the Accreditation & Quality Improvement Director, Director of Facilities and General Services Supervisor during the exit conference.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on records review with the Director of Facilities and General Services Supervisor on 02/15/22 at 12:50 p.m., the fire watch plan failed to include contacting the Indiana Department of Health (IDOH) via the IDOH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the IDOH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. Based on interview during the record review, the General Services Supervisor confirmed the fire watch documentation provided did not include information to contact IDOH via the IDOH Gateway link or at the e-mail address listed above.

This finding was reviewed with the Accreditation & Quality Improvement Directer, Director of Facilities and General Services Director during the exit conference.

Based on record review and interview, the facility failed to maintain automatic sprinkler systems in accordance with NFPA 25. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test and maintenance required by this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all residents, staff, and visitors in the facility.

Findings include:

Based on review of "System Inspection Certificate" documentation dated 10/19/21 during record review with the General Services Supervisor from 10:30 a.m. to 1:35 p.m. on 02/15/22, the Fire Hydrant located at Ground Southeast parking was in need of repair. The inpection report stated the fire hydrant failed the annual test with problem listed 'will not self drain'. Based on interview at the time of record review, the General Services Supervisor stated stated he was not aware there was a problem with the fire hydrant and documentation of the repair or replacement of the aforementioned fire hydrant on or after 10/19/21 was not available for review.

This finding was reviewed with the Accreditation & Quality Improvement Director, Director of Facilities and General Services Supervisor at the exit conference.

Based on record review and interview, the facility failed to conduct fire drills or documented orientation training on each shift for 4 of 4 quarters. LSC 19.7.1.6 states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. QSO-20-31 1135 temporary waiver states in lieu of a physical fire drill, a documented orientation training program related to the current fire plan, which considers current facility conditions, is acceptable. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. This deficient practice affects all staff and residents.

Findings include:

Based on record review on 02/15/22 with the General Services Supervisor at 1:10 p.m., the only completed fire drill within the last twelve months was conducted 04/20/2021 at 9:52 a.m. There were no other fire drills or documented orientation training related to the current fire plan to review for the past twelve month period. Based on interview at the time of record review, the General Services Supervisor stated the facility decided not to conduct fire drills due to the COVID19 Public Health Emergency, and the facility has discussed resuming fire drills in the near future. The General Services Supervisor confirmed there were no fire drill documentation or orientation training to review at the time of the survey.

This finding was reviewed with the Accreditation & Quality Improvement Director, Director of Facilities and General Services Supervisor at the exit conference.

1. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 1 of 1 generator during 1 of the past 12 months. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. Chapter 6-4.4.1.3 of 2012 NFPA 99 requires batteries for on-site generators shall be maintained in accordance with NFPA 110, 2010 Edition, Standard for Emergency and Standby Power Systems. 8.3.7 requires storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8.3.7.2 states defective batteries shall be repaired or replaced immediately upon discovery of defects. Chapter 6.5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on record review on 02/15/2022 between 10:30 a.m. and 1:35 p.m. with the Director of Facilities and General Services Supervisor present, there was no monthly generator load test documentation available for January of 2022. Based on interview at the time of record review, the General Services Supervisor confirmed there was no emergency generator load test documentation for January 2022.

2. Based on record review and interview, the facility failed to ensure a written record of weekly inspections for the generator was maintained for 14 of 52 weeks. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on record review with the General Services Supervisor on 02/15/22 from 10:30 a.m. to 1:35 p.m., documentation for the weeks of: January 3rd, 10th, 31st, December 20th & 27th, November 1st, October 11th, August 2nd & 23rd, July 19th, June 14th & 21st, May 24th and April 26th weekly generator testing was not available for review. Based on an interview at the time of record review, the General Services Supervisor confirmed weekly generator testing documentation for the aforementioned weeks was not available for review at the time of the survey.

These findings were reviewed with the Accreditation & Quality Improvement Director, Director of Facilities, and General Services Supervisor during the exit conference.