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Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 storage rooms with combustibles, measuring over 50 square feet in size, was provided with a self closing device. This deficient practice could affect four patients.

Findings include:

Based on observation with the Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 1:22 p.m., the corridor door to the clean utility room, measuring over 50 square feet in size, containing linen and blankets lacked a self closing device. This was confirmed by the Maintenance Foreman at the time of observation.

Based on record review and interview, the facility failed to include the use of alarms and transmission of alarms to the fire department in the written plan for the protection of 6 of 6 patients and for their evacuation in the event of an emergency. 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 patients in the facility.

Findings include:

Based on a review of the facility's written fire disaster plan titled "Emergency Fire Evacuation Plan" with the Maintenance Coordinator, Maintenance Foreman and the Assistant Director of Nursing (ADON) on 06/20/11 at 11:25 a.m., the fire plan did not address the use of alarms and the transmission of alarm to the fire department. This was acknowledged by the ADON at the time of record review.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters. This deficient practice could affect all occupants.

Findings include:

Based on review of the "Fire Drill Report Form" with the Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 12:25 p.m., there was no record of a third shift fire drill for the third quarter of 2010. Based on an interview with the Maintenance Foreman at the time of record review, no other documentation was available for review to verify this drill was conducted.

Based on observation and interview, the facility failed to ensure 1 of 1 smoke detectors in the 200 hall medical supply room was installed where air flow would not 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 four patients on the 100 hall.

Findings include:

Based on an observation with the Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 1:21 p.m., the smoke detector in the 200 hall medical supply room was located within three feet of an air supply duct. This was acknowledged by the Maintenance Foreman at the time of observation.

Based on observation and interview, the facility failed to install 1 of 1 fire alarm systems in accordance with NFPA 72, the National Fire Alarm Code. 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. This deficient practice could affect all occupants.

Findings include:

Based on an observation with Maintenance Coordinator, Maintenance Foreman and Assistant Director of Nursing (ADON) on 06/20/11 at 2:10 p.m., when the automatic dialer component was placed in trouble from phone line failure for five minutes no local trouble alarm was initiated. The trouble signal was not transmitted to the annunciator panel at the main entrance or the main fire alarm panel located in the electrical room. This was confirmed by Maintenance Foreman at the time of observation.

Based on observation and interview, the facility failed to ensure 21 of 21 smoke/fire dampers throughout the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. A CMS waiver for hospitals requires at least every 6 years, fusible links shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all occupants.

Findings include:

Based on observation with the Maintenance Foreman on 06/20/11 at 1:05 p.m., fire dampers were observed while in the mezzanine. Based on interview with the Maintenance Coordinator and the Maintenance Foreman, fire/smoke dampers were located throughout the facility. Based on interview with the Maintenance Foreman at 2:50 p.m. on 06/20/11, documentation stating the fire/smoke dampers have received an inspection was not available for review.

Based on observation and interview, the facility failed to have a policy for the use of 2 of 2 portable space heaters in the facility in accordance with NFPA 101, Section 19.7.8. This deficient practice was not in a patient care area but could affect any number of staff.

Findings include:

Based on observations with the Maintenance Coordinator, the Maintenance Foreman and the Assistant Director of Nursing (ADON) on 06/20/11 from 12:20 p.m. to 1:16 p.m., there was a space heater at the desk of the state liaison in the administration area and in the doctor's office. The space heaters were not in use at this time. Based on interview with the ADON at 2:40 p.m., the facility did not have a policy regarding the use of space heaters.

1. 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.

Findings include:

Based on an observation with Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 1:10 p.m., the emergency generator did not have a remote annunciator panel. Based on an interview with the Maintenance Foreman at the time of observation, he was not aware of this requirement.

2. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 11 of the last 12 months. Chapter 3-4.4.1.1 of 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 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating, whichever is greater, at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on review of the generator log "Weekly Preventative Maintenance for Standby Generator" with the Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 12:40 p.m., the only documentation of a generator load test was March 2011. Based on an interview with the Maintenance Foreman at the time of record review, no other documentation was available for review. Additionally, the generator log did not indicate whether the generator was exercised under operating conditions or not less than 30 percent of the EPS nameplate rating.

Based on record review and interview, the facility failed to protect 6 of 6 patients by providing a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for more than 4 hours 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, 11-2 requires an appointed sprinkler impairment coordinator. NFPA 25, 11-5 requires a preplanned program to include evacuation or an approved fire watch and 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 and 11-5(f) requires notification of supervisors in the area in addition to those already mentioned and lastly 11-7 requires notification of everyone again when the system is restored. This deficient practice could affect all occupants.

Findings include:

Based on review of the "Fire Watch Inspection Program" policy with the Maintenance Coordinator, the Maintenance Foreman and the Assistant Director of Nursing (ADON) on 06/20/11 at 11:34 p.m., the facility did have a written policy and procedure for an impaired sprinkler system available for review, but it did not address the following:
a) the designated person(s) shall have not other duties or responsibilities
b) the Indiana State Department of Health must be notified
c) the local fire department must be notified
Based on interview with the ADON at the time of record review, it was acknowledged the fire watch policy did not include the aforementioned items.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of 6 of 6 patients 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 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 affect all occupants.

Findings include:

Based on review of the "Fire Watch Inspection Program" policy with the Maintenance Coordinator, the Maintenance Foreman and the Assistant Director of Nursing (ADON) on 06/20/11 at 11:34 a.m., the facility did have a written policy and procedure for an impaired fire alarm system available for review, but it did not address the following:
a) the designated person(s) shall have not other duties or responsibilities
b) the Indiana State Department of Health must be notified
c) the local fire department must be notified
Based on interview with ADON at the time of record review, it was acknowledged the fire watch policy did not include the aforementioned items.

Based on observation and interview, the facility failed to ensure 2 of 2 alcohol based hand sanitizers in the Assistant Director of Nursing's (ADON) office and the doctor's office were not installed above or near an ignition source. NFPA 101, in 19.1.1.3 requires all health facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. This deficient practice was not in a patient care area but could affect any number of staff.

Findings include:

Based on observations with the Maintenance Coordinator, the Maintenance Foreman and the ADON on 06/20/11 from 1:00 p.m. to 1:15 p.m., alcohol based hand sanitizer dispensers were mounted on the wall above a light switch in the ADON's office and above a light switch in the doctor's office. This was acknowledged by the Maintenance Foreman at the time of the observations.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 storage rooms with combustibles, measuring over 50 square feet in size, was provided with a self closing device. This deficient practice could affect four patients.

Findings include:

Based on observation with the Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 1:22 p.m., the corridor door to the clean utility room, measuring over 50 square feet in size, containing linen and blankets lacked a self closing device. This was confirmed by the Maintenance Foreman at the time of observation.

Based on record review and interview, the facility failed to include the use of alarms and transmission of alarms to the fire department in the written plan for the protection of 6 of 6 patients and for their evacuation in the event of an emergency. 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 patients in the facility.

Findings include:

Based on a review of the facility's written fire disaster plan titled "Emergency Fire Evacuation Plan" with the Maintenance Coordinator, Maintenance Foreman and the Assistant Director of Nursing (ADON) on 06/20/11 at 11:25 a.m., the fire plan did not address the use of alarms and the transmission of alarm to the fire department. This was acknowledged by the ADON at the time of record review.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters. This deficient practice could affect all occupants.

Findings include:

Based on review of the "Fire Drill Report Form" with the Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 12:25 p.m., there was no record of a third shift fire drill for the third quarter of 2010. Based on an interview with the Maintenance Foreman at the time of record review, no other documentation was available for review to verify this drill was conducted.

Based on observation and interview, the facility failed to ensure 1 of 1 smoke detectors in the 200 hall medical supply room was installed where air flow would not 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 four patients on the 100 hall.

Findings include:

Based on an observation with the Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 1:21 p.m., the smoke detector in the 200 hall medical supply room was located within three feet of an air supply duct. This was acknowledged by the Maintenance Foreman at the time of observation.

Based on observation and interview, the facility failed to install 1 of 1 fire alarm systems in accordance with NFPA 72, the National Fire Alarm Code. 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. This deficient practice could affect all occupants.

Findings include:

Based on an observation with Maintenance Coordinator, Maintenance Foreman and Assistant Director of Nursing (ADON) on 06/20/11 at 2:10 p.m., when the automatic dialer component was placed in trouble from phone line failure for five minutes no local trouble alarm was initiated. The trouble signal was not transmitted to the annunciator panel at the main entrance or the main fire alarm panel located in the electrical room. This was confirmed by Maintenance Foreman at the time of observation.

Based on observation and interview, the facility failed to ensure 21 of 21 smoke/fire dampers throughout the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. A CMS waiver for hospitals requires at least every 6 years, fusible links shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all occupants.

Findings include:

Based on observation with the Maintenance Foreman on 06/20/11 at 1:05 p.m., fire dampers were observed while in the mezzanine. Based on interview with the Maintenance Coordinator and the Maintenance Foreman, fire/smoke dampers were located throughout the facility. Based on interview with the Maintenance Foreman at 2:50 p.m. on 06/20/11, documentation stating the fire/smoke dampers have received an inspection was not available for review.

Based on observation and interview, the facility failed to have a policy for the use of 2 of 2 portable space heaters in the facility in accordance with NFPA 101, Section 19.7.8. This deficient practice was not in a patient care area but could affect any number of staff.

Findings include:

Based on observations with the Maintenance Coordinator, the Maintenance Foreman and the Assistant Director of Nursing (ADON) on 06/20/11 from 12:20 p.m. to 1:16 p.m., there was a space heater at the desk of the state liaison in the administration area and in the doctor's office. The space heaters were not in use at this time. Based on interview with the ADON at 2:40 p.m., the facility did not have a policy regarding the use of space heaters.

1. 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.

Findings include:

Based on an observation with Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 1:10 p.m., the emergency generator did not have a remote annunciator panel. Based on an interview with the Maintenance Foreman at the time of observation, he was not aware of this requirement.

2. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 11 of the last 12 months. Chapter 3-4.4.1.1 of 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 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating, whichever is greater, at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on review of the generator log "Weekly Preventative Maintenance for Standby Generator" with the Maintenance Coordinator and the Maintenance Foreman on 06/20/11 at 12:40 p.m., the only documentation of a generator load test was March 2011. Based on an interview with the Maintenance Foreman at the time of record review, no other documentation was available for review. Additionally, the generator log did not indicate whether the generator was exercised under operating conditions or not less than 30 percent of the EPS nameplate rating.

Based on record review and interview, the facility failed to protect 6 of 6 patients by providing a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for more than 4 hours 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, 11-2 requires an appointed sprinkler impairment coordinator. NFPA 25, 11-5 requires a preplanned program to include evacuation or an approved fire watch and 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 and 11-5(f) requires notification of supervisors in the area in addition to those already mentioned and lastly 11-7 requires notification of everyone again when the system is restored. This deficient practice could affect all occupants.

Findings include:

Based on review of the "Fire Watch Inspection Program" policy with the Maintenance Coordinator, the Maintenance Foreman and the Assistant Director of Nursing (ADON) on 06/20/11 at 11:34 p.m., the facility did have a written policy and procedure for an impaired sprinkler system available for review, but it did not address the following:
a) the designated person(s) shall have not other duties or responsibilities
b) the Indiana State Department of Health must be notified
c) the local fire department must be notified
Based on interview with the ADON at the time of record review, it was acknowledged the fire watch policy did not include the aforementioned items.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of 6 of 6 patients 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 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 affect all occupants.

Findings include:

Based on review of the "Fire Watch Inspection Program" policy with the Maintenance Coordinator, the Maintenance Foreman and the Assistant Director of Nursing (ADON) on 06/20/11 at 11:34 a.m., the facility did have a written policy and procedure for an impaired fire alarm system available for review, but it did not address the following:
a) the designated person(s) shall have not other duties or responsibilities
b) the Indiana State Department of Health must be notified
c) the local fire department must be notified
Based on interview with ADON at the time of record review, it was acknowledged the fire watch policy did not include the aforementioned items.