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Based on record review and interview, the facility failed to maintain the inspection and servicing schedule of the commercial cooking suppression system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.2.3 and NFPA Standard 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2. This deficient practice affects one of four smoke zones and could affect all residents, staff, and visitors in the Dining Room. The facility had a capacity of 25 and a census of 15 at the time of the survey.

Findings include:

Record review on 09/28/2022 at 09:10 a.m. of the facility's cooking operations documentation, revealed the facility failed to maintain the Kitchen hood suppression system. The facility failed to have the fire-extinguishing system and listed exhaust hood inspected and serviced at least every six months by properly trained and qualified persons as required. The facility provided documentation of inspections by Iowa Fire Control dated 08/10/2022 and 05/27/2021.

Interview of the Maintenance Supervisor verified the documentation during the survey.

Based on record review and interview, the facility did not maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 Edition, 14.6.2.4, 14.3.1, and 14.4.5. The deficient practice of not conduction semi-annual inspections of the fire alarm system does not ensure proper operation and prompt repair, affecting all occupants. This facility had a capacity of 25 and a census of 15 residents at the time of the survey.

Findings include:

1. Record review on 09/28/2022 at 09:00 a.m., of the fire alarm inspection and testing forms conducted by Siemens revealed the fire alarm system was inspected and tested on 12/22/2021, however, there was no other documentation to support a second inspection.

2. Record review on 09/28/2022 between 9:18 a.m. and 10:00 a.m., revealed the facility did not contain any record of the emergency control functions for smoke damper operation being tested. The facility provided documentation from Midwest Alarm Systems of the test being performed by others. This documentation did not list if the smoke dampers passed or failed the test.

These deficient practices were confirmed by the Maintenance Supervisor.

Based on record review and interview, the facility failed to inspect and 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, 14.2, by not ensuring an internal inspection of the piping was conducted within the last five years. This deficient practice could affect all smoke compartments and occupants of the facility. The facility had a capacity of 25 and a census of 15 patients at the time of the survey.

Findings include:

1. Record review on 09/28/2022 at approximately 10:04 a.m., of the facility's sprinkler system inspection reports, revealed the facility was unable to provide documentation of an internal obstruction assessment of piping and branch line conditions. Interview of the Maintenance Supervisor confirmed no documentation could be located.

2. Observation on 09/28/2022 at 11:40 a.m., revealed the facility failed to maintain the sprinkler system in the "D" Conference Room # 1855. Two of three sprinkler heads contained dust and lint throughout.

3. Observation on 09/28/2022 at 11:42 a.m., revealed the facility failed to maintain the sprinkler system in Room #132. One of two sprinkler heads contained dust and lint throughout.

4. Observation on 09/28/2022 at 11:53 a.m., revealed the facility failed to maintain the sprinkler system in the Laboratory. Four of thirteen sprinkler heads contained dust and lint throughout.

5. Observation on 09/28/2022 at 12:17 p.m., revealed two of eight sprinkler heads in the Laundry Room contained dust and lint throughout.

6. Observation on 0/28/2022 at 12:21 p.m., revealed a missing escutcheon ring in the Kitchen. This was located by the east entrance to the service line.

These deficiencies were verified by the Maintenance Supervisor during the survey.

Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments, are smoke resisting and are positive latching as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. This deficient practice affected one of four smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 15 residents at the time of the survey.

Findings include:

Observation on 09/28/2022 at 11:51 a.m., revealed a door to the Laboratory was propped open by a rubber door wedge.

The Maintenance Supervisor confirmed the finding at the time of discovery.

Based on observation and interview, the facility is not assuring that two of 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. This deficient practice affects all residents, staff, and visitors in one of four smoke zones. The facility has a capacity of 25 with a census of 15.

Findings include:

Observation on 09/28/2022 at 12:18 p.m., revealed the lay in tile at the public entrance to the Pharmacy had an approximately two inch by two inch hole.

The Maintenance Supervisor confirmed this finding during the survey.

Based on record review and interview, the facility failed to conduct fire drills 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 15 residents at the time of survey.

Findings include:

Record review on 09/28/2022 at 10:10 a.m., of the facility's fire drill documentation, revealed first, second, and third shift drills were conducted at approximately the same time of day. Three first shift drills were conducted between 8:31 a.m., 8:37 a.m., and 8:40 a.m.: on 07/07/2022 at 8:31 a.m., 01/06/2022 at 8:37 a.m., and 04/29/2022 at 8:40 a.m. Four second shift drills were conducted between 2:50 p.m. and 3:40 p.m.: on 03/23/2022 at 2:50 p.m., 06/07/2022 at 3:00 p.m., 09/29/2021 at 3:07 p.m., and 12/07/2021 at 3:40 p.m. Three third shift drills were conducted between 5:20 p.m. and 6:19 p.m.: on 02/06/2022 at 5:20 p.m., 05/10/2022 at 6:07 p.m., and 11/04/2021 at 6:19 p.m. The Maintenance Director verified the documentation during the survey process.