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Based on surveyor observation and staff interview, the facility failed to maintain exits unobstructed at all times. This deficient practice affects 4 patients in 1 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and interview on 11/29/18 at 11:00 a.m., revealed no sidewalk to a public way from the Southeast exit from the 2011 south zone. This is not a required exit but an exit sign was located above this door.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain doors in vertical openings in accordance with National Fire Protection Association (NFPA) 80, 2010 edition. This deficient practice affects 5 staff members in 3 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and interview on 11/29/18 revealed the following deficiencies:

1. At 10:28 a.m., an approximately 3/8-inch gap between the fire doors to the 1949 second floor west stair doors.
2. At 10:29 a.m., an approximately 3/8-inch gap between the fire doors to the 1949 second floor south stair doors.
3. At 10:30 a.m., a gap greater than 1/8-inch between the south elevator enclosure doors on the second floor of the 1949 building.

Administrative Staff A and Maintenance Staff A observed these findings.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72. This deficient practice affects 4 patients in 15 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and staff interview on 11/29/18 at 9:46 a.m., revealed the facility failed to provide documentation of testing (every 6 years) of the fire/smoke dampers.

Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to provide an outage policy in accordance with National Fire Protection Association (NFPA) 101, 2012 edition. This deficient practice affects 4 patients in 15 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 11/29/18 at 9:58 a.m., revealed the following deficiencies:

1. The fire alarm system outage policy did not list the contact numbers for the Iowa Department of Inspections and Appeals or the Iowa State Fire Marshal.
2. The fire alarm system outage policy stated rounds of the affected areas shall be completed every 30 minutes. However, the fire alarm system outage policy failed to state the fire watch shall be "continuous".

Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25. This deficient practice affects 4 patients in 15 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 11/29/18 at 9:32 a.m., revealed the facility failed to provide documentation of quarterly maintenance of the sprinkler system.

Administrative Staff A and Maintenance Staff A observed this finding.

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 4 patients in 15 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 11/29/18 at 10:02 a.m., revealed the following deficiencies:

1. The sprinkler system outage policy did not address system leakage, interruption of water supply, ruptured piping, or equipment failure.
2. The sprinkler system outage policy did not address the notification of the supervisors in the areas affected by the outage.
3. The sprinkler system outage policy did not address a tag impairment system.
4. The sprinkler system outage policy did not address the assembly of all necessary tools and materials on the impairment site.
5. The sprinkler system outage policy did not state phone numbers for the Iowa Department of Inspections and Appeals, the Iowa State Fire Marshal, or the facility's insurance carrier.
6. The sprinkler system outage policy stated rounds of the affected areas shall be completed every 30 minutes. However, the sprinkler system outage policy failed to state the fire watch shall be "continuous".

Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to provide documentation for fire drills conducted quarterly on each shift. This deficient practice affects 4 patients in 15 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and staff interview on 11/29/18 at 10:08 a.m., revealed the facility failed to provide documentation of fire drills conducted during the overnight shift.

Maintenance 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 1 patient in 1 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and interview on 11/29/18 at 10:55 a.m., revealed storage obstructing access to the electrical panel in the Med Surge Data Closet.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to provide generator test documentation in accordance with National Fire Protection Association (NFPA) 99. This deficient practice affects 4 patients in 15 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review on 11/29/18 revealed the following deficiencies:

1. At 9:38 a.m., the generator monthly test log failed to indicate the meter readings & the meter start and stop times.
2. At 9:39 a.m., the facility failed to provide documentation of an annual test (in accordance with ASTM) of the emergency generator fuel supply.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to provide electrical surge protectors in accordance with National Fire Protection Association (NFPA) 70 & 99. This deficient practice affects 1 staff member in 1 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and interview on 11/29/18 at 10:45 a.m., revealed a toaster plugged into a multi-plug surge-protector strip in Environmental Services.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain oxygen cylinder storage in accordance with National Fire Protection Association (NFPA) 99, 2012 edition. This deficient practice affects 4 patients in 1 of 15 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and interview on 11/29/18 at 10:59 a.m., revealed no signage designating the full and empty oxygen cylinders in the oxygen storage room located across from Room 19.

Administrative Staff A and Maintenance Staff A observed this finding.