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Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72 by ensuring that an approved visible fire alarm strobe was provided to give visible warning of a fire emergency. This deficient practice could affect residents, staff and visitors in the first floor. The facility has a capacity of 25 with a census of six.

Findings include:

Observation and interview on 06/14/2021 at 1:13 p.m., revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm did not have a functioning visual strobe for the E.R. Public Bathroom.

The Facilities & Materials Management Director verified 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. 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 25 and a census of six residents at the time of the survey.

Findings include:

Record review and interview on 06/14/2021 at 09:36 a.m. revealed the facility was unable to produce a fire alarm outage policy. No policy could be reviewed at the time of inspection.

The Facilities & Materials Management Director verified the documentation at the time of the survey process.

Based on record review and interview, the facility failed to maintain the automatic sprinkler system within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.4.1.6 and 14.2, by not providing a five year internal inspection of the sprinkler piping. This deficient practice could affect all smoke compartments and occupants of the facility. The facility had a capacity of 25 and a census of six residents at the time of the survey.

Findings include:


Observation and interview on 06/14/2021 at about 9:18 a.m., revealed the five year internal sprinkler inspection had not been conducted. The last documented internal sprinkler inspection conducted was 05/09/2011.

The Facilities & Materials Management Director verified these findings at the time of the survey.

Based on 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 sprinkler system is out of service for more than 10 hours in any 24-hour period. 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 25 and a census of six residents at the time of the survey.

Findings include:

Interview on 06/14/2021 at about 09:15 a.m. revealed the facilities sprinkler outage policy was missing therefore could not be reviewed at the time of inspection. A completed policy shall address all the following information:

1. Assigning an impairment coordinator.

2. 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.

3. 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.

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

5. 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.

6. When using a fire watch, the fire watch designee shall be Dedicated to the fire watch task. The fire watch shall also be Continuous while the sprinkler system is out of service.

The Facilities & Materials Management Director verified the documentation at the time of the survey process.

Based on observation and interview, the facility is not providing doors to the corridor that resist the passage of smoke in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.6.3. This deficient practice would not prevent the spread of smoke, affecting one smoke compartment and any residents, staff, and visitors in the Kitchen area. This facility has a capacity of 25 with a census of six.

Findings include:

Observation and interview on 06/14/2021 at about 12:11 p.m., revealed the Kitchen door had a door stop mounted on the door itself. This door can only be held open with a electronic hold open device tied in to the fire alarm system.

The Facilities & Materials Management Director verified this observation during the survey process.

Based on observation and interview, the facility is not assuring that two smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. These deficient practices affects residents, staff, and visitors in these affected areas. The facility has a capacity of 25 with a census of six.

Findings include:

1. Observations and interview on 06/14/2021 at about 12:16 p.m., revealed the smoke barrier between the Physical Therapy Room and its Mechanical Room had a 1 1/2" hole due to a pipe that had been cut off and had not been filled in.

2. Observations and interview on 06/14/2021 at about 1:25 p.m., revealed an approximately one inch hole in the Air Handler 3 West Wall. Piping had been cut in the past and the piping has been left open allowing the passage of smoke to the next compartment.

The Facilities & Materials Management Director verified these observations during the survey process.

Based on record review and interview, the facility failed to provide an adequate evacuation and relocation plan and procedure in case of fire plan for the evacuation of the building's smoke zones directly affected by fire in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1 and 19.7.2. This deficient practice affects all smoke zones, residents, staff, and visitors. The facility had a capacity of 25 and a census of six residents at the time of the survey.

Findings include:

Record review and interview on 06/14/2021 at about 10:26 a.m. revealed the facility had no Fire Safety Plan to have reviewed.

The Facilities & Materials Management Director confirmed this lack of documentation during the survey process.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, 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 had a capacity of 25 and a census of six residents at the time of survey.

Findings include:

Record review and interview on 06/14/2021 at about 10:31 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct fire drills on all shifts at varied times during all quarters of the year. Only one fire drill was being conducted during each quarter.

The Maintenance Supervisor verified the documentation during the survey process.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all residents, staff, and visitors. The facility had a capacity of 25 and a census of six residents at the time of the survey.

Findings include:

Record review and interview on 06/14/2021 at about 10:56 a.m., revealed the facility was unable to provide documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Interview of the Maintenance Supervisor revealed the facility had not documented this testing.

The Facilities & Materials Management Director and Maintenance Supervisor confirmed this finding at the time of the survey.

Based on record review and interview, the facility failed to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of six residents at the time of the survey.

Findings include:

Record review and interview on 06/14/2021 at about 11:21 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator's diesel fuel.

Record review and interview on 06/14/2021 at about 11:22 a.m., revealed the facility had not established a annual program for the testing of its Main and Feeder circuit breakers with in its EES in accordance with the manufacturer's recommendation.

The Maintenance Supervisor confirmed these findings at the time of the survey.