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Based on record review, observation and interview; the facility failed to ensure 1 of 1 fire barriers to nonconforming buildings were protected by a two hour fire wall. Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following:
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.
NFPA 80, section 2-3.1.7 states the clearance between the meeting edges of doors swinging in pairs on the pull side shall not exceed 1/8 inch.
This deficient practice could affect all patients, staff and visitors if smoke from a fire were to infiltrate the tenant separation wall.

Findings include:

Based on observations with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the set of 90 minute fire resistance rated self closing fire doors by Pod J in the two hour tenant separation fire barrier wall which separates the orthopedic surgical center (Building 06) from the outpatient physical therapy and MRI building (Building 07) failed to latch into the door frame. Each of the aforementioned doors in the door set was provided with a latching mechanism which was "dogged down" and failed to protrude into the latching plate. In addition, the set of 90 minute fire resistance rated automatic closing fire doors near the main entrance on the south side of the building in the aforementioned two hour tenant separation fire barrier could not be closed in order to ensure the clearance between the meeting edges of the door set swinging in pairs did not exceed 1/8 inch and would latch into the door frame. The door set was not provided with an astragal, rabbet or bevel. Based on interview at the time of the observations, the Building Superintendent stated the automatic closing fire doors in the tenant separation wall on the south side of the building can only be closed with fire alarm system activation and acknowledged the two sets of fire doors in the fire barrier for a nonconforming building did not ensure the orthopedic surgical center was protected by a two hour fire wall.

Based on observation and interview, the facility failed to enclose 1 of 3 stairwell vertical openings with construction having a fire resistance rating of one hour. This deficient practice could affect 20 staff and visitors.

Findings include:

Based on observation with the Maintenance Tech during a tour of the facility from 10:00 a.m. to 1:00 p.m. on 12/16/15, the two inch annular space surrounding a one inch in diameter open ended conduit which penetrated the east wall of the northwest stairwell above the suspended ceiling in the second floor office area was not firestopped to maintain the fire resistance rating of the stairwell wall. Based on interview at the time of observation, the Maintenance Tech acknowledged the aforementioned hole in the stairwell wall failed to maintain a fire resistance rating of one hour for the stairwell vertical opening.

Based on observation and interview, the facility failed to enclose 1 of 3 stairwells with construction having a fire resistance rating of one hour. This deficient practice could affect 20 staff and visitors.

Findings include:

Based on observation with the Maintenance Tech during a tour of the facility from 10:00 a.m. to 1:00 p.m. on 12/16/15, the two inch annular space surrounding a one inch in diameter open ended conduit which penetrated the east wall of the northwest stairwell above the suspended ceiling in the second floor office area was not firestopped to maintain the fire resistance rating of the stairwell wall. Based on interview at the time of observation, the Maintenance Tech acknowledged the aforementioned hole in the stairwell wall failed to maintain a fire resistance rating of one hour for the stairwell.

Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 6 exits was readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. Such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect four patients, staff and visitors if the facility were required to evacuate the building from the northwest exit at the back of the surgery area.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the northwest exit discharge at the back of the surgery area led to a grass covered lawn and not to the public way. Based on interview at the time of observation, the Building Superintendent acknowledged the aforementioned exit did not lead to a public way.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on the first shift for 3 of 4 quarters and on the second shift for 4 of 4 quarters. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on review of "Alarm: Monitoring Procedure for Fire Drill" and "Code Red Evaluation" documentation with the Building Superintendent during record review from 8:30 a.m. to 11:30 a.m. on 12/17/15, the following was noted:
a. second shift (6:00 p.m. to 6:00 a.m.) fire drills conducted on 03/11/15, 06/10/15, 09/09/15 and 12/16/15 were conducted at, respectively, 6:10 p.m., 7:05 p.m., 6:08 p.m. and 6:45 p.m.
b. first shift (6:00 a.m. to 6:00 p.m.) fire drills were conducted on 03/11/15, 06/10/15 and 09/09/15 which was the same day second shift quarterly fire drills were conducted in the first, second and third quarter of 2015.
Based on interview at the time of record review, the Building Superintendent acknowledged the aforementioned first and second shift fire drills were not conducted at unexpected times under varying conditions.

1. Based on observation and interview, the facility failed to provide annunciation for 1 of 1 fire alarm systems in accordance with NFPA 72. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code, 1999 Edition. 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 patients, staff and visitors.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the facility's main fire alarm control panel (FACP) was located in the first floor Mechanical Room which is not continuously occupied and remote from any area where continuous on site monitoring from the surgery suite could occur, such as the nurses' station. Based on interview at the time of observation, the Building Superintendent stated the FACP was monitored off site but was not provided with an onsite audible trouble alarm in the surgery suite or in an area where trouble signals are likely to be heard.

2. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 9.6.2.10 refers to NFPA 72, the National Fire Alarm Code. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the facility's main fire alarm control panel was located in the first floor Mechanical Room which is not continuously occupied. Based on interview at the time of observation, the Building Superintendent acknowledged the Mechanical Room which contains the facility's main fire alarm control panel is not continuously occupied and was not provided with automatic smoke protection.

Based on observation and interview, the facility failed to ensure 1 of over 200 smoke detectors was 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 16 patients, staff and visitors in the facility.

Findings include:

Based on observation with the Maintenance Tech during a tour of the facility from 10:00 a.m. to 1:00 p.m. on 12/16/15, one smoke detector was installed on the ceiling six inches from an air supply vent in the corridor outside Room 202. Based on interview at the time of observation, the Maintenance Tech acknowledged a smoke detector was installed on the ceiling six inches from an air supply vent in the corridor outside Room 202.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the machine room provided the means is independent of the elevator control and cannot be self-resetting; The activation of sprinklers outside the machine room is not to disconnect the main line power supply and smoke detectors are not used to activate the sprinkler I the machine room or to disconnect the main line power supply. This deficient practice could affect twenty, staff and visitors in the vicinity of the second floor elevator machine room.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the elevator machine room on the second floor lacked sprinkler coverage. Based on interview at the time of observation, the Building Superintendent acknowledged the elevator machine room lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 6 of 6 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the machine room provided the means is independent of the elevator control and cannot be self-resetting; The activation of sprinklers outside the machine room is not to disconnect the main line power supply and smoke detectors are not used to activate the sprinkler I the machine room or to disconnect the main line power supply. This deficient practice could affect all patients, staff and visitors in the vicinity of the elevator machine rooms.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 10:30 a.m. to 2:30 p.m. on 12/16/15, the four elevator machine room in the basement and two elevator machine rooms on first floor lacked sprinkler coverage. Based on interview at the time of observation, the Building Superintendent acknowledged the elevator machine rooms lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, no evidence of a remote manual stop device was found for the emergency generator which was located outside the building on the north side. The nameplate affixed to the emergency generator stated it was manufactured in April 2010 and was rated at 505 kW. Based on interview at the time of observation, the Building Superintendent acknowledged a remote manual stop device was not found for the emergency generator.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Maintenance Tech during a tour of the facility from 10:00 a.m. to 1:00 p.m. on 12/16/15, no evidence of a remote manual stop device was found outside the room housing the emergency generator. Based on interview at the time of observation, the Maintenance Tech stated the emergency generator was installed after 2003 and acknowledged a remote manual stop device was not found outside the room housing the emergency generator.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 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 residents, staff and visitors.

Findings include:

Based on review of "Safety & Disaster Manual: Fire Watch" documentation with the Building Superintendent during record review from 8:30 a.m. to 11:30 a.m. on 12/17/15, the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH), which is the authority having jurisdiction, the fire alarm monitoring company and the building owner. Based on interview at the time of record review, the Building Superintendent acknowledged the written fire watch policy in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH, the fire alarm monitoring company and the building owner.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 fire barriers to nonconforming buildings were protected by a two hour fire wall. Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following:
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.
NFPA 80, section 2-3.1.7 states the clearance between the meeting edges of doors swinging in pairs on the pull side shall not exceed 1/8 inch.
This deficient practice could affect all patients, staff and visitors if smoke from a fire were to infiltrate the tenant separation wall.

Findings include:

Based on observations with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the set of 90 minute fire resistance rated self closing fire doors by Pod J in the two hour tenant separation fire barrier wall which separates the orthopedic surgical center (Building 06) from the outpatient physical therapy and MRI building (Building 07) failed to latch into the door frame. Each of the aforementioned doors in the door set was provided with a latching mechanism which was "dogged down" and failed to protrude into the latching plate. In addition, the set of 90 minute fire resistance rated automatic closing fire doors near the main entrance on the south side of the building in the aforementioned two hour tenant separation fire barrier could not be closed in order to ensure the clearance between the meeting edges of the door set swinging in pairs did not exceed 1/8 inch and would latch into the door frame. The door set was not provided with an astragal, rabbet or bevel. Based on interview at the time of the observations, the Building Superintendent stated the automatic closing fire doors in the tenant separation wall on the south side of the building can only be closed with fire alarm system activation and acknowledged the two sets of fire doors in the fire barrier for a nonconforming building did not ensure the orthopedic surgical center was protected by a two hour fire wall.

Based on observation and interview, the facility failed to enclose 1 of 3 stairwell vertical openings with construction having a fire resistance rating of one hour. This deficient practice could affect 20 staff and visitors.

Findings include:

Based on observation with the Maintenance Tech during a tour of the facility from 10:00 a.m. to 1:00 p.m. on 12/16/15, the two inch annular space surrounding a one inch in diameter open ended conduit which penetrated the east wall of the northwest stairwell above the suspended ceiling in the second floor office area was not firestopped to maintain the fire resistance rating of the stairwell wall. Based on interview at the time of observation, the Maintenance Tech acknowledged the aforementioned hole in the stairwell wall failed to maintain a fire resistance rating of one hour for the stairwell vertical opening.

Based on observation and interview, the facility failed to enclose 1 of 3 stairwells with construction having a fire resistance rating of one hour. This deficient practice could affect 20 staff and visitors.

Findings include:

Based on observation with the Maintenance Tech during a tour of the facility from 10:00 a.m. to 1:00 p.m. on 12/16/15, the two inch annular space surrounding a one inch in diameter open ended conduit which penetrated the east wall of the northwest stairwell above the suspended ceiling in the second floor office area was not firestopped to maintain the fire resistance rating of the stairwell wall. Based on interview at the time of observation, the Maintenance Tech acknowledged the aforementioned hole in the stairwell wall failed to maintain a fire resistance rating of one hour for the stairwell.

Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 6 exits was readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. Such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect four patients, staff and visitors if the facility were required to evacuate the building from the northwest exit at the back of the surgery area.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the northwest exit discharge at the back of the surgery area led to a grass covered lawn and not to the public way. Based on interview at the time of observation, the Building Superintendent acknowledged the aforementioned exit did not lead to a public way.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on the first shift for 3 of 4 quarters and on the second shift for 4 of 4 quarters. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on review of "Alarm: Monitoring Procedure for Fire Drill" and "Code Red Evaluation" documentation with the Building Superintendent during record review from 8:30 a.m. to 11:30 a.m. on 12/17/15, the following was noted:
a. second shift (6:00 p.m. to 6:00 a.m.) fire drills conducted on 03/11/15, 06/10/15, 09/09/15 and 12/16/15 were conducted at, respectively, 6:10 p.m., 7:05 p.m., 6:08 p.m. and 6:45 p.m.
b. first shift (6:00 a.m. to 6:00 p.m.) fire drills were conducted on 03/11/15, 06/10/15 and 09/09/15 which was the same day second shift quarterly fire drills were conducted in the first, second and third quarter of 2015.
Based on interview at the time of record review, the Building Superintendent acknowledged the aforementioned first and second shift fire drills were not conducted at unexpected times under varying conditions.

1. Based on observation and interview, the facility failed to provide annunciation for 1 of 1 fire alarm systems in accordance with NFPA 72. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code, 1999 Edition. 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 patients, staff and visitors.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the facility's main fire alarm control panel (FACP) was located in the first floor Mechanical Room which is not continuously occupied and remote from any area where continuous on site monitoring from the surgery suite could occur, such as the nurses' station. Based on interview at the time of observation, the Building Superintendent stated the FACP was monitored off site but was not provided with an onsite audible trouble alarm in the surgery suite or in an area where trouble signals are likely to be heard.

2. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 9.6.2.10 refers to NFPA 72, the National Fire Alarm Code. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the facility's main fire alarm control panel was located in the first floor Mechanical Room which is not continuously occupied. Based on interview at the time of observation, the Building Superintendent acknowledged the Mechanical Room which contains the facility's main fire alarm control panel is not continuously occupied and was not provided with automatic smoke protection.

Based on observation and interview, the facility failed to ensure 1 of over 200 smoke detectors was 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 16 patients, staff and visitors in the facility.

Findings include:

Based on observation with the Maintenance Tech during a tour of the facility from 10:00 a.m. to 1:00 p.m. on 12/16/15, one smoke detector was installed on the ceiling six inches from an air supply vent in the corridor outside Room 202. Based on interview at the time of observation, the Maintenance Tech acknowledged a smoke detector was installed on the ceiling six inches from an air supply vent in the corridor outside Room 202.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the machine room provided the means is independent of the elevator control and cannot be self-resetting; The activation of sprinklers outside the machine room is not to disconnect the main line power supply and smoke detectors are not used to activate the sprinkler I the machine room or to disconnect the main line power supply. This deficient practice could affect twenty, staff and visitors in the vicinity of the second floor elevator machine room.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, the elevator machine room on the second floor lacked sprinkler coverage. Based on interview at the time of observation, the Building Superintendent acknowledged the elevator machine room lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 6 of 6 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the machine room provided the means is independent of the elevator control and cannot be self-resetting; The activation of sprinklers outside the machine room is not to disconnect the main line power supply and smoke detectors are not used to activate the sprinkler I the machine room or to disconnect the main line power supply. This deficient practice could affect all patients, staff and visitors in the vicinity of the elevator machine rooms.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 10:30 a.m. to 2:30 p.m. on 12/16/15, the four elevator machine room in the basement and two elevator machine rooms on first floor lacked sprinkler coverage. Based on interview at the time of observation, the Building Superintendent acknowledged the elevator machine rooms lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Building Superintendent during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15, no evidence of a remote manual stop device was found for the emergency generator which was located outside the building on the north side. The nameplate affixed to the emergency generator stated it was manufactured in April 2010 and was rated at 505 kW. Based on interview at the time of observation, the Building Superintendent acknowledged a remote manual stop device was not found for the emergency generator.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Maintenance Tech during a tour of the facility from 10:00 a.m. to 1:00 p.m. on 12/16/15, no evidence of a remote manual stop device was found outside the room housing the emergency generator. Based on interview at the time of observation, the Maintenance Tech stated the emergency generator was installed after 2003 and acknowledged a remote manual stop device was not found outside the room housing the emergency generator.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 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 residents, staff and visitors.

Findings include:

Based on review of "Safety & Disaster Manual: Fire Watch" documentation with the Building Superintendent during record review from 8:30 a.m. to 11:30 a.m. on 12/17/15, the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH), which is the authority having jurisdiction, the fire alarm monitoring company and the building owner. Based on interview at the time of record review, the Building Superintendent acknowledged the written fire watch policy in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH, the fire alarm monitoring company and the building owner.