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Based on observations and staff interview, the facility failed to maintain all 2 hour rated walls, including doors at least 1-1/2 hour fire rated in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observations and staff interview on 3/1/17 at 1:41 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 4 inches by 5 inches), around communications cables extending through the 2 hour rated wall to the Medical Surgery Unit from the Surgery Unit.
2. There was a penetration, (approximately 4 inches by 6 inches), around communications cables and conduit extending through the 2 hour rated wall to the Medical Surgery Unit from the Surgery Unit.
3. There was a penetration, (1 inch), around conduit extending through the 2 hour rated wall to the Medical Surgery Unit from the Surgery Unit.
4. There were two penetrations, ( both approximately 1 inch), around 2 conduit extending through the 2 hour rated wall to the Medical Surgery Unit from the Surgery Unit.
5. There was a penetration, (approximately 1-1/2 inch), around communications cables extending through the 2 hour wall by the Diagnostic Procedure Waiting Room.

Maintenance Staff verified observations during the survey process.

Based record review and staff interview, the facility failed to test and maintain the emergency lighting system in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 7.9 and 19.2.9.1. A monthly test of the system for 30 seconds shall be conducted. A yearly test of the system for 90 minutes shall be conducted. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 8 residents.

Findings include:

Record review and staff interview on 3/1/17, between 10:00 a.m. and 3:00 p.m., revealed the following deficiencies:
1. The test log for the emergency lighting unit did not list the location of each emergency lighting unit as required.
2. There was no available documentation of testing of the emergency lighting system for the following months: January 2016, March 2016, April 2016, May 2016, June 2016, July 2016, August 2016.
Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility failed to maintain all stairwells with a fire resistance rating of a minimum of one hour in accordance with National Fire Protection Association, 2012 Life Safety Code, 19.3.1.1 through 19.3.1.6. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observation and staff interview on 3/1/17 at 1:56 p.m., revealed the 2nd Floor North Stairwell Fire Door failed to close and latch properly when tested. Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, the facility is not properly separating hazardous areas from other compartments. Hazardous areas shall be separated from other compartments by fire rated construction and self-closing doors in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.2.1. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observations and staff interview on 3/1/17, between 10:00 a.m. and 3:00 p.m., revealed the following deficiencies:
1. The door to the Basement Hot Water Heater Room by the Maintenance office is not equipped with an automatic closure device and a label indicating the fire resistance rating.
2. The door to the Basement Storage Room by Purchasing has a hole, (approximately 1 inch), through the door. The door also does not have a label indicating the fire resistance rating.
3. The door to the North Boiler Room did not close and latch properly when tested.
4. The door to the Laboratory has 4 holes, (all approximately 1/4 inch), through the door.
Maintenance Staff verified observations during the survey process.

Based on observations, record review and staff interview, the facility failed to inspect and service the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observations, record review and staff interview on 3/1/17 at 2:42 p.m., revealed the following deficiencies:

1. There was no available documentation of monthly inspections for the Kitchen Hood and Duct Extinguishment System.
2. During inspection of the medical clinic facility staff reported an odor of natural gas to Maintenance Staff. Maintenance Staff indicated the odor may be coming from the Kitchen. Observation of the Kitchen range top revealed two pilots that were not lit.

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to inspect and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. A fire alarm system shall be inspected twice a year, at an interval of 6 months. Smoke detectors shall be tested for sensitivity every 2 years. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Record review and staff interview on 3/1/17 at 11:16 a.m., revealed the last available documentation of smoke detector sensitivity testing was completed on 2/9/11. There was no available documentation of testing after that date. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 8 residents.

Findings include:

Record review and staff interview on 3/1/17 at 10:21 a.m., revealed the outage policy for the fire alarm system did not contain notification of the Iowa Department of Inspections and Appeals, (DIA), as joint authority having jurisdiction. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Record review and staff interview on 3/1/17 at 2:42 p.m., revealed no available documentation of a sprinkler system inspection for the 3rd Quarter of 2016. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 8 residents.

Findings include:

Record review and staff interview on 3/1/17 at 10:21 a.m., revealed the outage policy for the sprinkler system did not contain notification of the Iowa Department of Inspections and Appeals, (DIA), as joint authority having jurisdiction. Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, the facility failed to maintain and test fire extinguishers as required by National Fire Protection Association, NFPA 10, 2010 edition. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observations and staff interview on 3/1/17 at 12:46, revealed the following deficiencies:

1. There was no documentation of monthly inspections for the fire extinguisher in the corridor outside the Laundry Room for the months of May, June and July of 2016.
2. There was no documentation of monthly inspections for the fire extinguisher in the North Boiler Room for the months of May, June and July of 2016.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observation and staff interview on 3/1/17 at 1:12 p.m., revealed an open pipe, (approximately 1 inch), extending through the Smoke Barrier Wall to the Shipping Corridor. Maintenance Staff verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills and maintain proper documentation of fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Record review and staff interview on 3/1/17 at 10:53 a.m., revealed the following deficiencies:
1. The facility failed to hold fire drills under varied conditions at different times of the day for the 1st Shift as follows: 3/23/16 at 9:30 a.m.
9/14/16 at 9:30 a.m. 12/16/16 at 9:50 a.m.
2. The facility failed to hold fire drills under varied conditions at different times of the day for the 2nd Shift as follows: 1/21/16 at 9 p.m.
4/11/16 at 9 p.m. 7/11/16 at 8:30 p.m.
Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility is not testing and maintaining smoke control systems in accordance with National Fire Protection Association, 2012 Life Safety Code, 19.7.7 and National Fire Protection Association, NFPA 92. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Record review and staff interview on 3/1/17 at 11:16 a.m., revealed no available documentation of smoke damper testing/inspection. Maintenance Staff verified record review during the survey process.

Based on observations, record review and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. A weekly inspection of the generator shall be conducted. monthly test under load shall be conducted. A remote manual stop station shall be provided for each generator set. The deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observations, record review and staff interview on 3/1/17, between 10:00 a.m. and 3:00 p.m., revealed the following deficiencies:

1. The facility has not installed remote manual stop stations for each generator set.
2. There were gaps in the generator weekly inspection log as follows: 3/2/16 to 3/16/16. 4/13/16 to 4/27/16. 4/27/16 to 5/11/16. 7/27/16 to 8/10/16. 9/7/16 to 9/21/16. 9/28/16 to 10/12/16. 11/23/16 to 12/7/16. 12/14/16 to 1/4/17. 1/18/17 to 2/22/17. During these time frames weekly inspections for both generator sets were not documented.
3. Facility staff is not ensuring each diesel powered generator is operated under load at 30% of the nameplate value during monthly tests.

Maintenance Staff verified observations and record review during the survey process.

Based on observation and staff interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 2010 Edition. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observation and staff interview on 3/1/17 at 12:34 p.m., revealed the following deficiencies:

1. There was a cracked cover on an electrical outlet in the Maintenance Office.
2. There was an electrical outlet without a cover in the Maintenance Office.
3. There was a conduit with an open junction box in the Maintenance Office near Electrical Panel B-4.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 2010 Edition. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observation and staff interview on 3/1/17 at 12:34 p.m., revealed an extension cord supplying power to a grinder in the Maintenance Office. Maintenance Staff verified observations during the survey process.