HospitalInspections.org

Based on surveyor observation and staff interview, the facility failed to provide delayed-egress doors in accordance with National Fire Protection Association (NFPA), 101, 2012 edition. This deficient practice affects 2 patients in 1 of 55 zones. The facility has a capacity of 220 and a census of 108.

Findings include:

Observations and interview on 08/04/17 at 11:15 am., revealed no signs on the delayed-egress doors out of 4-South OB (Obstetrics) stating the following:

PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Administrative Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to provide interior finish with a Class A or B flame spread rating. This deficient practice affects 12 patients in 6 of 55 zones. The facility has a capacity of 220 and a census of 108.

Findings include:

Observations and interview on 08/04/17 at 11:58 a.m., revealed the facility failed to provide documentation of the flame spread rating of 5 murals located on the south walls of the landings in Stairwell 12.

Administrative Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, 2010 edition. This deficient practice affects 2 patients in 1 of 55 zones. The facility has a capacity of 220 and a census of 108.

Findings include:

Observations and interview on 08/04/17 at 12:23 p.m., revealed the smoke detector in 2104E was located within 3-feet of a HVAC (Heating, Ventilation, and Air Conditioning) supply.

Administrative Staff A observed this finding.

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72 2010 Edition 10.5.5, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected this would affect all of the building occupants.. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 220 with a census of 108.

Findings include:

Observation and interview on 8-4-17, the facility failed to provide a properly maintained fire alarm system in the Medical Arts Building. The fire alarm breaker located in the electrical room electrical panel HT breaker #1 was not secured with a mechanical lock to assure the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Observation and interview on 8-4-17, the facility failed to provide a properly maintained fire alarm system in the Transitions Building. The fire alarm breaker located in the Basement electrical panel breaker #28 was not secured with a mechanical lock to assure the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff (A) verified this observation.

Based on record review and staff interview, the facility failed to provide an outage policy in accordance with National Fire Protection Association (NFPA) 25, 2011 edition. This deficient practice affects 108 patients in 55 of 55 zones. The facility has a capacity of 220 and a census of 108.

Findings include:

Record review and interview on 08/04/17 at 10:37 a.m., revealed the sprinkler system outage policy did not include notifying the Iowa State Fire Marshal, the Iowa Department of Inspections and Appeals, and the facility's insurance company.

Administrative Staff A observed this finding.

LIFETIME FITNESS CENTER

Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25, 5.2.1.1*, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of four smoke zones. The facility had a capacity of 220 and a census of 108 at the time of survey.

Findings include:

Observation and interview on 8-4-17 at approximately 12:00 p.m., revealed that in the Northeast Exercise Room the ceiling sprinkler head next to the corridor door was covered with dust.

Maintenance Staff (A) verified this observation.

Based on record review and staff interview, the facility failed to provide an outage policy in accordance with National Fire Protection Association (NFPA) 25, 2011 edition. This deficient practice affects 108 patients in 55 of 55 zones. The facility has a capacity of 220 and a census of 108.

Findings include:

Record review and interview on 08/04/17 at 10:37 a.m., revealed the sprinkler system outage policy did not include notifying the Iowa State Fire Marshal, the Iowa Department of Inspections and Appeals, and the facility's insurance company.

Administrative Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to provide doors to the corridor that resist the passage of smoke. This deficient practice affects 2 patients in 1 of 55 zones. The facility has a capacity of 220 and a census of 108.

Findings include:

Observations and interview on 08/04/17 at 11:55 a.m., revealed the gap between the doors to 2507 was greater than 1/8-inch when the doors were in the closed position.

Administrative Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70, 2011 edition. This deficient practice affects 2 patients in 2 of 55 zones. The facility has a capacity of 220 and a census of 108.

Findings include:

Observations and interview on 08/04/17, revealed the following deficiencies:
1. At 10:45 a.m., exposed electrical wires on the ceiling of 4911.
2. At 12:10 p.m., a temporary halogen light was located in the Spray Booth. This light is not approved for use in Spray Booths.

Administrative Staff A observed this finding.