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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 the patients as well as visitors and staff.

Findings include:

Based on observation with the Supervisor of General Services on 04/20/12 during the tour from 1:15 p.m. to 2:15 p.m., the remote alarm annunciator for the generator was located in the boiler room. Based on interview at the time of observation, the Supervisor of General Services acknowledged the generator remote alarm annunciator was not located in a location readily observed by operating personnel at a regular work station such as a nurses' station and indicated staff may hear the annunciator if close by.

2. Based on interview and record review, the facility failed to ensure the off site fuel source for 1 of 1 emergency generators was from a reliable source. NFPA 110 1999 Edition, Standard for Emergency and Standby Power Systems, Chapter 3, Emergency Power Supply (EPS), 3-1.1, Energy Sources states the following energy sources shall be permitted for use for the emergency power supply (EPS):
a) Liquid Petroleum products at atmospheric pressure
b) Liquefied petroleum gas (liquid or vapor withdrawal)
c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of offsite fuel supplies is high (e.g., due to earthquake, flood damage or demonstrated utility unreliability), on-site storage of an alternate energy source sufficient to allow full output of the emergency power supply system (EPSS) to be delivered for the class specified shall be required, with provision for automatic transfer from the primary energy source to the alternate energy source.
CMS (Centers for Medicare/Medicaid Services) requires a letter of reliability from the natural gas vendor regarding the fuel supply that must contain the following:
1. A statement of reasonable reliability of the natural gas delivery.
2. A brief description that supports the statement regarding the reliability.
3. A statement that there is a low probability of interruption of the natural gas.
4. A brief description that supports the statement regarding the low probability of interruption,
5. The signature of a technical person from the natural gas provider.
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on interview with the Supervisor of General Services on 04/20/12 during documentation review from 11:30 a.m. to 1:15 p.m., the fuel source for the emergency generator was natural gas. Additionally, based on record review, the facility did have a letter from their natural gas provider (NIPSCO) dated 02/24/09 but the letter did not include all the items above required for a letter confirming the reliability of a natural gas fuel source for an emergency generator. The letter lacked supporting statements of reliability of natural gas and low probability of interruption of the natural gas service. This was acknowledged by the Supervisor of General Services during the time of record review.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with remote manual stops. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the Generator Maintenance records on 04/20/12 during review of documentation from 11:30 a.m. to 1:15 p.m. with the Supervisor of General Services, there was no documentation available which indicated the amount of horsepower the generator was provided. Based on observation of generator equipment on between 1:15 p.m. and 2:15 p.m. during a tour of the facility with the Supervisor of General Services, there a remote shut off device was not found for the generator. Based on interview during the time of observation, the Supervisor of General Services indicated the generator was installed in 1998.

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 the patients as well as visitors and staff.

Findings include:

Based on observation with the Supervisor of General Services on 04/20/12 during the tour from 1:15 p.m. to 2:15 p.m., the remote alarm annunciator for the generator was located in the boiler room. Based on interview at the time of observation, the Supervisor of General Services acknowledged the generator remote alarm annunciator was not located in a location readily observed by operating personnel at a regular work station such as a nurses' station and indicated staff may hear the annunciator if close by.

2. Based on interview and record review, the facility failed to ensure the off site fuel source for 1 of 1 emergency generators was from a reliable source. NFPA 110 1999 Edition, Standard for Emergency and Standby Power Systems, Chapter 3, Emergency Power Supply (EPS), 3-1.1, Energy Sources states the following energy sources shall be permitted for use for the emergency power supply (EPS):
a) Liquid Petroleum products at atmospheric pressure
b) Liquefied petroleum gas (liquid or vapor withdrawal)
c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of offsite fuel supplies is high (e.g., due to earthquake, flood damage or demonstrated utility unreliability), on-site storage of an alternate energy source sufficient to allow full output of the emergency power supply system (EPSS) to be delivered for the class specified shall be required, with provision for automatic transfer from the primary energy source to the alternate energy source.
CMS (Centers for Medicare/Medicaid Services) requires a letter of reliability from the natural gas vendor regarding the fuel supply that must contain the following:
1. A statement of reasonable reliability of the natural gas delivery.
2. A brief description that supports the statement regarding the reliability.
3. A statement that there is a low probability of interruption of the natural gas.
4. A brief description that supports the statement regarding the low probability of interruption,
5. The signature of a technical person from the natural gas provider.
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on interview with the Supervisor of General Services on 04/20/12 during documentation review from 11:30 a.m. to 1:15 p.m., the fuel source for the emergency generator was natural gas. Additionally, based on record review, the facility did have a letter from their natural gas provider (NIPSCO) dated 02/24/09 but the letter did not include all the items above required for a letter confirming the reliability of a natural gas fuel source for an emergency generator. The letter lacked supporting statements of reliability of natural gas and low probability of interruption of the natural gas service. This was acknowledged by the Supervisor of General Services during the time of record review.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with remote manual stops. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the Generator Maintenance records on 04/20/12 during review of documentation from 11:30 a.m. to 1:15 p.m. with the Supervisor of General Services, there was no documentation available which indicated the amount of horsepower the generator was provided. Based on observation of generator equipment on between 1:15 p.m. and 2:15 p.m. during a tour of the facility with the Supervisor of General Services, there a remote shut off device was not found for the generator. Based on interview during the time of observation, the Supervisor of General Services indicated the generator was installed in 1998.