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Based on record review and interview, the facility failed to document periodic testing of emergency lighting equipment in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.2.9.1 and 7.9.3. This deficient practice affects battery backup emergency light fixtures located throughout the building. The facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Record review on 8/20/19 at 10:10 a.m., revealed the facility was unable to provide documentation of annual functional testing for any battery backup emergency light fixture throughout the building. Interview of the Maintenance Supervisor revealed the facility had been conducting periodic testing of emergency lighting fixtures, but the last 90 minute annual test was conducted in July of 2018.

The Maintenance Supervisor and the Administrator confirmed these findings during the survey process.

Based on observation and interview, the facility failed to provide self-closing separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2.1.3. This deficient practice affects one of five smoke zones and could affect 20 residents, staff, and visitors within the affected zone. The facility had a capacity of 17 residents and a census of 4.

Findings include:

1. Observation and interview on 08/20/2019 at 12:30 p.m., revealed the Basement Storage Closet located within the Kitchen exceeded 50 square feet in size and did not contain a self-closing device on the closet door. This closet was being used to store chemical cleaning supplies and other combustible material. The Maintenance Supervisor confirmed this observation at the time of the survey process.

2. Observation and interview on 8/20/2019 at 11:50 p.m., revealed the South Patient Hall Pharmacy Storage Room exceeded 50 square feet in size and did not contain a self-closing device on the closet door. This closet storage room was being used to store pharmaceutical boxes and miscellaneous combustible items. The Maintenance Supervisor confirmed this observation at the time of the survey process.

The Maintenance Supervisor confirmed these observations 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 17 and a census of 4 residents at the time of the survey.

Findings include:

Record review and interview on 08/20/2019 at 10:05 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Interim Life Safety Management Policy, revealed the policy language did not include the fire watch designee to be 'dedicated' and that the fire watch is 'continuous'. The Maintenance Supervisor verified the documentation at the time of the survey process.

Based on observation and interview, the facility is not providing properly inspected sprinkler pipe in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.2.2, by allowing an external load by material resting or hung from the pipe. This deficient practice does not affect any residents in the Basement of the facility. The facility had a capacity of 17 with a census of 4 residents at the time of the survey..

Findings include:

1. Observation and interview on 8/20/19, at 12:25 p.m., revealed blue IT cables attached with plastic zip ties to the sprinkler pipe in the Maintenance Area of the Basement. No residents are residing in the room at the time of the survey.

The Maintenance Supervisor verified this observation 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 41 and a census of 31 residents at the time of the survey.

Findings include:

Record review on 8/20/19 at 9:55 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.

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. The facility will contact entities at the beginning & conclusion of fire watch, and that the fire watch designee is "dedicated" and fire watch is "continuous"

Maintenance Supervisor A verified the documentation at the time of the survey process.

Based on observation, record review and interview, the facility did not ensure corridor doors fit tightly within the doorframe to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. Double doors did not have an astragal (to close the gap between meeting edges of doors) to ensure the doors were smoke resisting. This deficient practice affected all occupants in two of five smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

1. Observation and interview on 08/20/2019 at 12:10 p.m. and 12:11 p.m., revealed the following corridor doors in the East Patient Hall did not have an astragal installed(to close the gap between meeting edges of doors) to ensure the doors were smoke resisting. These patient room doors are double doors located within the corridor.

a) At 12:10 p.m., Resident Room 223.
b) At 12:10 p.m., Resident Room 225.
c) At 12:11 p.m., Resident Room 226.
d) At 12:11 p.m., Resident Room 228.

2. Observation and interview on 8/20/2019 at 12:35 p.m., revealed the Office Supply Room corridor door located in the basement did not have an astragal installed(to close the gap between meeting edges of doors) to ensure the doors were smoke resisting.. This corridor door is a double door located within the corridor.

Record review of the facility layout showed these doors protected two of five smoke zones.


The Maintenance Supervisor confirmed these observations during the survey process.

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 17 and a census of 4 residents at the time of survey.

Findings include:

Record review and interview on 08/20/2019 at 10:40 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 9:05 a.m. and 10:00 a.m.: a first quarter drill at 10:05 a.m., a second quarter drill at 9:05 a.m., and a third quarter drill at 10:10 a.m. Three second shift drills were conducted between 3:05 p.m. and 3:25 p.m.: a first quarter drill at 3:20 p.m., second quarter drill at 3:25 p.m., and a fourth quarter drill at 3:05 p.m. Three third shift drills were conducted between 5:25 a.m. and 5:35 a.m.: a second quarter drill was conducted at 5:25 a.m., a third quarter drill was conducted at 5:35 a.m., and a fourth quarter drill was conducted at 5:30 a.m. The Maintenance Supervisor verified the documentation during the survey process.

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 Protective's, 5.2. This deficient practice affects all residents, staff, and visitors in five of five smoke compartments. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

1. Record review and interview on 08/20/2018 at 10:25 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. The facility has attached buildings that are separated by two-hour fire doors. 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 Staff A revealed the facility staff was unaware of the inspection requirement and verified this finding during the survey.

2. Record review on 08/20/2019 at 10:25 a.m., revealed the facility could not provide full documentation of annual inspection and testing of fire and/or smoke door assemblies within the facility. Interview of Maintenance Supervisor revealed the facility staff was unaware of the inspection requirements and verified this finding during the survey.

The Maintenance Supervisor confirmed the documentation at the time of the survey.


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, the facility failed to document electrical receptacle testing at the time of install 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 one of five smoke compartments and all residents, staff, and visitors. The facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Record review on 08/20/2019 at 11:05 a.m., revealed the facility was unable to provide documentation of hospital-grade receptacle testing at the time of installation at patient bed locations throughout the facility. Interview of the Maintenance Supervisor revealed the facility completed the hospital-grade receptacle installations several years ago and was unsure where the documentation is kept.

The Maintenance Supervisor confirmed this finding at the time of the survey.

Based on record review and interview, the facility failed to maintain and test essential electrical system (EES) circuitry as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2., failed to provide a remote manual stop for the emergency generator as required by NFPA Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 5.6.5.6., and failed to provide an annual fuel quality test as required by NFPA Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8. These deficient practices affects all of the smoke compartments throughout the building and all occupants. The facility had a capacity of 45 and a census of 26 residents at the time of the survey.

Findings include:

1. Record review and interview on 08/20/2019 at 11:05 a.m., revealed the facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers. Interview of the Maintenance Supervisor revealed the facility was unaware of this testing.

2. Observations and interview on 08/20/2019 at 11:25 a.m., revealed the facility's emergency generator was not equipped with a remote manual stop mechanism (emergency shut-off) external to the weatherproof enclosure. The Maintenance Supervisor verified this observation at the time of the survey process.

3. Record review and interview on 08/20/2019 at 10:20 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.


NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, 5.6.5.6

5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

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