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Based on record review and interview, the facility did not develop and maintain a complete emergency preparedness plan in accordance with the Code of Federal Regulations, 42 CFR §483.475(a) [ICF]/ §483.73(a) [LTC], by failing to review and update the plan at least annually. This deficient practice affects all occupants of the facility. The facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review on 10/11/2021 at 9:10 a.m., revealed the facility's emergency preparedness plan did not contain documentation of an annual review date or any updates made to the emergency plan based on a review. Interview of the Maintenance Director indicated he was not aware of any other documentation outside of the emergency preparedness program binder that may have specified an annual review.

The Maintenance Director verified this finding during the survey process.

Based on record review and interview, the facility did not develop and maintain complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR §483.475(b) [ICF]/§483.73(b) [LTC], by failing to verify the policies and procedures have been reviewed and updated on an annual basis. This deficient practice affects all occupants of the facility. The facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review on 10/11/2021 at 9:17 a.m., revealed the facility's emergency preparedness policies and procedures did not contain documentation that verified they had been reviewed and updated at least annually. Interview of the Administrative Staff Member in charge of Emergency Preparedness indicated he was not aware of any other documentation outside of the emergency preparedness program binder that may have specified an annual review.

Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR §483.73(b)(6), by failing to address the facilitation of volunteer support from individuals with varying levels of skills and training. This deficient practice affects all occupants of the facility. The facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 10/11/2021 at 9:13 a.m., revealed the facility did not have a documented procedure for privileging and credentialing volunteering healthcare professionals to be able to perform services within their scope of practice and training in the event the facility may need to accept volunteer support during an emergency. An Administrative Staff Member in charge of Emergency Preparedness verified this finding during the survey process.

Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR 483.475(b)(8) [ICF]/ 483.73(b)(8) [LTC], by failing to incorporate policies and procedures in its emergency plan describing the facility's role under a waiver in accordance with Social Security Act, Section 1135, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice affects all occupants of the facility. The facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 10/11/2021 at 9:15 a.m., revealed the facility's emergency preparedness policies and procedures did not specifically address the facility's role in emergencies where the Health and Human Services Secretary declares a public health emergency. The emergency preparedness plan failed to demonstrate the facility's general awareness of the 1135 process, including the following:

1) Knowledge of how to request a waiver and who to contact (contact information) in the event an 1135 waiver needs to be requested;

2) The circumstances when an 1135 waiver might be granted based on the risk analysis;

3) How they would operate under and outline the responsibilities during the duration of the waiver period; and

4) How they would plan jointly on issues related to staffing, equipment, and supplies.

The Administration Staff Member in charge of Emergency Preparedness verified this finding during the survey process.

Based on record review and interview, the facility did not maintain a written emergency preparedness communications plan in accordance with the Code of Federal Regulations, 42 CFR §483.475(c) [ICF]/§483.73(c) [LTC], by failing to provide evidence the communications plan had been reviewed (and updated as necessary) on an annual basis. This deficient practice affects all occupants of the facility. The facility had a capacity of 22 and a census of 6 clients at the time of the survey.

Findings include:

Record review on 10/11/2021 at 9:22 a.m., revealed the facility's emergency preparedness communication plan did not contain documentation that verified it had been reviewed and updated at least annually. Interview of the Administrative Staff Member in charge of Emergency Preparedness indicated he was not aware of any other documentation outside of the emergency preparedness program binder that may have specified an annual review.
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Based on observation and interview, it was determined the facility did not provide appropriate construction standards as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.1.6. The two-story facility failed to assure minimum building construction requirements were maintained by ensuring that ceiling tiles are maintained to prevent the penetration of smoke through smoke zones. This deficient practice affected one smoke zone and all staff in the basement of the facility. The facility had a capacity of 22 with a census of 6 residents at the time of the survey.

Findings include:

Observation and interview on 10/11/2021 at 10:38 a.m., revealed the facility failed to maintain the ceiling in the corridor hallway, outside the elevator in the Basement. This corridor contained a broken ceiling tile in the lay in ceiling tile. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. This deficient practice affects one light fixture on the Second Floor of the facility. It affects all staff and no residents on this floor. The facility has a capacity of 22 and a census of 6.

Findings include:

Observation and interview on 10/11/2021 at 11:11 a.m., revealed the battery backup emergency light labeled number 13, located in the Hallway of the Physical Therapy on the Second Floor of the Main Building failed to illuminate when tested. The Maintenance Coordinator verified this observation at the time of the survey process.

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Based on observations and interviews, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2. This deficient practice affects one smoke zone and could affect all residents, staff, and visitors within the affected zone corridor. The facility had a capacity of 22 residents and a census of 6 at the time of the survey.

Findings include:

Observation and interview on 10/11/2021 at 10:57 a.m., revealed the corridor door leading to the Environmental Services Storage Room was equipped with a self-closure device but failed to close and positively latch within the door frame. The Maintenance Coordinator confirmed this observation at the time of the survey process.

Based on record review and interview, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 10/11/2021 between 10:10 a.m. and 11:05 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Fire Watch - Fire Alarm policy, revealed the policy did not instruct facility personnel to contact the local fire department, Iowa Department of Inspections and Appeals (DIA; Authority Having Jurisdiction), State Fire Marshal's Office or the insurance carrier at the beginning or conclusion of the fire watch or include any procedures for how to conduct a fire watch.

The Maintenance Coordinator and the Administrator verified the documentation at the time of the survey process.

Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review on 10/11/2021 at 9:51 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was incomplete in that it did not address and was missing the following information:

1. Tagging an impaired system that has been removed from service at each fire department connection and the system control valve indicating which system, or part thereof, has been removed from service.

2. All preplanned impairments shall be authorized by the impairment coordinator, who shall verify the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(6) The insurance carrier has been notified and its phone number.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented.
(9) All necessary tools and materials have been assembled on the impairment site.

3. Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

4. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The insurance carrier, alarm company, and Iowa DIA have been advised that protection is restored.
(5) The impairment tag has been removed.

Maintenance Coordinator verified the documentation at the time of the survey process.

Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review on 10/11/2021, at 10:04 a.m. revealed the fire plan did not address the following information:

The plan did not address all the types of fire extinguishers and how to use them or information about the range hood suppression system.

The Maintenance Coordinator verified this finding at the time of the survey.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for one 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 had a capacity of 22 and a census of 6 residents at the time of survey.

Findings include:

Record review and interview on 10/11/2021 at 8:49 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct a fire drill during the first shift for the fourth quarter of the 2020/2021 period. The Nursing Staff Fire Drill coordinator verified the documentation during the survey process. She stated maintenance staff personnel were not available during this period to disable the fire doors and duct dampers.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects all residents, staff, visitors in one smoke compartment. This facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 10/11/2021 at 10:27 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. This fire doors are required to be functionally tested annually by an individual with knowledge and understanding of the operating components of the type of door being subject to testing. Interview of Maintenance Coordinator revealed he was aware of the inspection requirement and he thought it was last completed in 2017 or 2018.


NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects all residents, staff, visitors in one smoke compartment. This facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 10/11/2021 at 10:27 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. This fire doors are required to be functionally tested annually by an individual with knowledge and understanding of the operating components of the type of door being subject to testing. Interview of Maintenance Coordinator revealed he was aware of the inspection requirement and he thought it was last completed in 2017 or 2018.


NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Based on observation and interview, the facility did not prohibit the use of extension cords beyond temporary installation or as a substitute for adequate wiring in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition and NFPA 70, National Electrical Code, 2011 edition. This deficient practice may create electrical injury and fire hazards affecting staff in the Basement of the facility. This facility had a capacity of 22 and a census of 6 residents at the time of the survey.

Findings include:

1. Observation on 10/11/2021 at 10:40 a.m., revealed the sump pump in the Environmental Services Room was plugged into an orange extension cord which was plugged into an electrical receptacle in the wall.

2. Observation on 10/11/2021 at 10:40 a.m., revealed the an orange extension cord was plugged into an outlet in the Environmental Services Room. This extension cord transversed through the west wall into the North Maintenance Room and supplied power to a clothes dryer vent booster fan.

This deficient practice was confirmed by the Maintenance Coordinator.