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Based on observation and interview, the facility failed to provide a durable sign with a contrasting background indicating how to operate the delayed egress locking mechanism in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.2.2.4 and 7.2.1.6.1.1(4). This deficient practice affects 12 patients in 1 of 55 zones. This facility had a capacity of 220 and a census of 137 residents at the time of the survey.

Findings include:

Observation and interview on 11/19/19 at 11:18 a.m. revealed the exit door to the central stairwell on the 5th floor was equipped with a 15-second delay lock. A readily visible, durable sign in letters not less than 1 inch high and not less than 1/8-inch in stroke width on a contrasting background that reads as follows was not provided on the door leaf located adjacent to the release device in the direction of egress:

PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Maintenance Staff A & B 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 24 patients in 2 of 55 zones. The facility has a capacity of 220 and a census of 137.

Findings include:

Observations and interview on 11/19/19 at 9:50 a.m. revealed the following deficiency:

1. An approximately 3/4-inch gap between the north elevator enclosure doors on 3rd floor of the West Tower.


Maintenance Staff A & B observed this finding.

Based on observation and interview, the facility failed to provide a one hour enclosure for fuel-fired heating equipment located in the basement in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.2.1.2 and 8.4. This deficient practice would affect all occupants in 1 of 55 zones. This facility had a capacity of 220 and a census of 137 residents at the time of the survey.

Findings include:

Observation and interview on 11/19/19 at 1:55 p.m. revealed an approximately 18-inch by 6-inch hole through the ceiling of the basement Boiler Room at the Story City PT/Rehab.

Maintenance Staff A confirmed this observation at the time of discovery.

Based on interview and record review, the facility did not assure that an adequate policy is in place regarding the procedures to be taken in the event that the fire alarm 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 written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This deficient practice affects all occupants of the building. The facility has a capacity of 220 and a census of 137.

Findings include:

Record review and interview on 11/18/19 at 2:40 p.m. revealed the policy failed to include the following:

1. The fire alarm system outage policy failed to state the fire watch rounds are "continuous" with rounds of the affected areas completed at least every 30 minutes.

Maintenance Staff A & B observed this finding.

Based on observation and staff interview, the facility failed to provide smoke detectors in accordance with National Fire Protection Association (NFPA) 72, 2010 edition . This deficient practice affects all occupants in 1 of 55 zones. The facility has a capacity of 220 and a census of 137.

Findings include:

Observations and interview on 11/19/19 at 12:13 p.m. revealed a smoke detector located within 3-feet of a HVAC supply vent in Physical Therapy in the Medical Arts Building.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to provide a sprinkler system in accordance with National Fire Protection Association (NFPA) 70, 2011 edition. This deficient practice affects 84 patients in 14 of 55 zones. The facility has a capacity of 220 and a census of 137.

Findings include:

Observations and interview on 11/19/19 at 9:37 a.m., revealed the air compressors (5) for the dry sprinkler systems in the West Tower were plugged into wall outlets and not "hard-wired".

Maintenance Staff A and B observed this finding.

Based on interview and record review, this facility did not assure that a 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. This facility had a capacity of 220 and a census of 137 residents at the time of the survey.

Findings include:

Record review and interview on 11/18/19 at 2:40 p.m., of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 10 hours in a 24-hour period. The policy failed to have the following information included in their policy as required by NFPA 25, 2011 Edition (Chapter 15):

1. The sprinkler system outage policy failed to state the fire watch rounds are "continuous" with rounds of the affected areas completed at least every 30 minutes.

Maintenance Staff A & B observed this finding.

Based on observation and interview, the facility failed to maintain corridor walls to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.6.2.4. This deficient practice affects 12 patients in 1 of 55 zones. This facility had a capacity of 220 and a census of 137 residents at the time of the survey.

Findings include:

Observations and interview on 11/19/19 at 11:04 a.m. revealed a residential washer and dryer located in a closet off the corridor in Behavioral Health (near 6209). This room was not separated from the exit corridor.

Maintenance Staff A & B observed this finding.

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, 19.7.1 and 19.7.2. This deficient practice affects all occupants of the facility. This facility had a capacity of 220 and a census of 137 residents at the time of the survey.

Findings include:

Record review and interview on 11/18/19 at 2:55 p.m., revealed the following Fire Safety Plan deficiencies:

1. The Fire Safety Plan failed to address the use of the hood extinguishment system in the Kitchen.

Maintenance Staff A & B 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 all occupants in 2 of 55 zones. The facility has a capacity of 220 and a census of 137.

Findings include:

Observations and interview on 11/19/19 revealed the following deficiencies:

1. At 11:45 a.m., a table obstructing access to the electrical panel in the Ambulance Garage storage room.
2. At 1:56 p.m., exposed electrical wiring on a temporary construction light on the ceiling of the basement Boiler Room in the Story City PT/Rehab.

Maintenance Staff A & B observed these findings.

Based on observation and interview, the facility did not maintain the use of surge protector strips in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition and NFPA 70, National Electrical Code, 2011 edition. These deficient practices may create electrical injury and fire hazards affecting 5 employees in 1 of 55 smoke zones. This facility had a capacity of 220 and a census of 137 at the time of the survey.

Findings include:

Observation and interview on 11/19/19 at 12:01 p.m., revealed a treadmill plugged into a multiplug strip in Medical Records.

Maintenance Staff A & B observed this finding.