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Based on observation and interview, the facility failed to ensure 3 of more than 100 corridor doors were free from impediments to closing. This deficient practice affects patients, staff and visitors in the resident room smoke compartments on the fifth and sixth floors.

Findings Include:

Based on observations made between 1:20 p.m. and 2:30 p.m. on 01/25/11 with the maintenance supervisor and facility administrator, the corridor doors to patient rooms 5213, 5216 and 6216 were blocked open by infection control boxes hung on the corridor side of the resident room doors. The maintenance supervisor and administrator stated at the time of observation, they were not aware of the problem and would come to a mutual solution.

Based on record review and interview, the facility failed to have 1 of 1 written health care occupancy fire safety plans that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to 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 effects all patients, staff and visitors in the event of an emergency on the fifth and sixth floors.

Findings include:

Based on record review on 01/25/11 at 11:30 a.m. with the facility's administrator, the facility did not have a complete written health care occupancy fire safety plan or procedure. The Evacuation Policy did not contain procedures for residents being safely transferred to a specific meeting area or have a transfer agreement with another facility, staff being periodically trained in specific duties to be performed in the event of an evacuation and preparations to evacuate immediate areas, smoke compartments and the building. The administrator stated at the time of the record review, he was aware of the requirements but could not produce emergency policies or procedures for direct care staff and patients.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 4 of the last 4 quarters. This deficient practice could effect all patients, staff and visitors in the event of an emergency on the fifth and sixth floors.

Findings include:

Based on review of the facility's Fire Drill records and interview on 01/24/11 at 2:25 p.m. with the maintenance supervisor and facility administrator, there was no record of first quarter fire drills for any shift, a first shift fire drill for the second quarter, a second shift fire drill for the third quarter or a second and third shift shift fire drill for the fourth quarter of 2010. The administrator stated at the time of record review, he was not aware of the problem.

Based on interview and observation, the facility failed to provide evidence of required maintenance of 1 of 1 fire alarm systems. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 7-1.1.2 requires system defects and malfunctions shall be corrected. NFPA 72, 7-5.2.2 requires a permanent record of all inspections, testing, and maintenance records shall be provided. This deficient practice effects all patients, staff and visitors in the event of an emergency on the fifth and sixth floors.

Findings include:

During an alarm system test with the maintenance supervisor and facility administrator on 01/25/11 between 1:15 p.m. and 1: 45 p.m., the strobes connected to the alarm system failed to activate. The maintenance supervisor stated at the time of observations, the failure had been noted by Simplex on 12/14/10. He also stated he had no idea or plan as to when the failure of the strobes would be repaired. The system failure was observed to have affected only the fifth and sixth floors.

Based on record review and interview, the facility failed to ensure sprinkler gauges for 1 of 1 sprinkler systems were tested every five years. NFPA 25, Section 2-3.2 states gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall shall be recalibrated or replaced. This deficient practice could affect all patients, staff and visitors on the fifth and sixth floors.

Findings include:

Based on record review with the maintenance supervisor on 01/24/11 at 2:50 p.m., the Simplex inspection reports dated for 2010 did not indicate the pressure gauges had been replaced or recalibrated. The maintenance supervisor stated at the time of record review, he was sure the gauges lacked a calibration sticker indicating the date calibrated or replaced, and he stated the gauges had not been replaced or calibrated.

Based on record review and interview, the facility failed to ensure 1 of 1 hood extinguishing systems in the kitchen was inspected and serviced every six months. LSC 9.2.3 requires commercial cooking equipment to be in compliance with NFPA 96, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, at 8-3.1 requires an inspection and servicing of the fire extinguishing system for moderate volume cooking operations at least every six months by properly trained and qualified staff persons. This deficient practice could effect patients, staff and visitors in and near the ground floor kitchen area.

Findings include:

Based on observation of the hood extinguishing system inspection documentation at 1:20 p.m. on 01/25/11 with the maintenance supervisor, the kitchen hood extinguishing system had been inspected and serviced on 01/14/11. The service paperwork for the hood cleaning indicated the previous inspection was 01/20/10, a period greater than six months. The maintenance supervisor stated at the time of record review, the kitchen hood exhaust system is cleaned and inspected professionally annually.

Based on record review, observation and interview; the facility failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 52 of 52 weeks for 4 generator sets. Chapter 3-4.4.1.3 of NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires storage batteries, including electrolyte levels, be inspected at intervals of not more than 7 days. Chapter 3-4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs be regularly maintained and available by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors on the fifth and sixth floors.

Findings include:

Based on review of the generator logs with the maintenance supervisor on 01/24/11 at 2:45 p.m., the facility did not test or exercise the emergency generator battery at seven day intervals. The maintenance supervisor stated at the time of record review, he did not understand the seven day inspection requirement.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed to protect 70 of 70 patients 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 to 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 to be notified. This deficient practice could affect all occupants in the facility including patients, staff and visitors on the fifth and sixth floors.

Findings include:

Based on review of the facility's policy and procedure book with the maintenance supervisor and facility administrator on 01/25/11 at 11:35 a.m., the fire watch procedure for an out of service automatic sprinkler system was incomplete. The procedure lacked the telephone number for the Indiana State Department of Health (317-233-5359) and the local fire department, it did not include staff must be trained and designated to perform fire watch rounds. The policy did not include a statement about what procedures are to be implemented in the event the sprinkler system should be out of service. At the time of the record review, the administrator indicated no other policy or procedure was available to review.

Based on record review and interview, the facility failed to provide a complete written policy containing 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 to protect 70 of 70 patients, 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 patients, staff and visitors on the fifth and sixth floors.

Findings include:

Based on review of the facility's policy and procedure book with the facility administrator on 01/25/11 at 11:35 a.m., the fire watch procedure for an out of service automatic alarm system was not complete. The procedure lacked the telephone number for the Indiana State Department of Health (317-233-5359) and the local fire department, it did not include staff must be trained and designated to perform fire watch rounds. The policy did not include a statement about what procedures are to be implemented in the event the fire alarm system should be out of service. At the time of record review, the administrator indicated no other policy or procedure was available to review.