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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 21 and a census of eight residents at the time of the survey.

Findings include:


Record review and interview on 09/01/2020 at about 12:42 p.m. of the fire watch procedures for a fire alarm system outage in the facility's Fire Alarm System Shutdown policy, revealed the policy did not state the employee assigned to the fire watch would be "dedicated" only to the fire watch duties as required.

The Maintenance Supervisor 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. 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 21 and a census of eight residents at the time of the survey.

Findings include:

Record review on 09/01/2020 at about 12:30 p.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 all the following required items.

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.

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

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, 314.25, by not ensuring each box in completed installations shall have a cover. This deficient practice affects staff in the Kitchen utility area. The facility has a capacity of 21 and a census of eight.

Findings Include:

1. Observation and interview on 09//01/2020 at about 3:15 p.m., revealed the facility failed to maintain the electrical system in the Boiler Room. This room contained a four inch by four inch open junction box that had exposed 12GA wires. This junction box is required to have a cover.

2. Observation and interview on 09/01/2020 at about 3:00 p.m., revealed the facility failed to maintain the electrical system in the Kitchens Laundry Room area. This room had an outlet with in six feet of a water source behind the washing machine that was not protected by a GFCI outlet.

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

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 staff, residents and visitors. The facility had a capacity of 21 and a census of eight residents at the time of the survey.

Findings include:

Record review and interview on 09/01/2020 at 1:45 p.m. of the facility's fire response plan, revealed the policy did not include the use of the Ansul hood suppression system in the Kitchen. Interview of the Maintenance Supervisor revealed the facility had not added this training of the use of the hood suppression system in their fire response plan.

The Maintenance Supervisor confirmed the documentation during the survey process.