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Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR §483.73(b)(6), by failing to address the facilitation of volunteer support from individuals with varying levels of skills and training. This deficient practice affects all occupants of the facility. The facility had a capacity of 22 and a census of six residents at the time of the survey.

Findings include:

Record review and interview on 11/12/2019 at 12:18 p.m., revealed the facility did not have a documented procedure for privileging and credentialing volunteering healthcare professionals to be able to perform services within their scope of practice and training in the event the facility may need to accept volunteer support during an emergency. The Maintenance Supervisor verified this finding during the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects two smoke compartments in the building. This could affect all staff in the service areas. The facility has a capacity of 22 and a census of six.

Findings include:

Observation and interview on 11/12/2019 at 12:31 p.m., revealed the facility failed to separate the Garbage Room from other compartments. The Garbage Room contained an one inch hole and a 1/4 inch hole in the ceiling. The Maintenance Supervisor 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 22 and a census of six residents at the time of the survey.

Findings include:

Record review and interview on 11/12/2019 at 09:21 a.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 that the employee assigned to the fire watch shall be "dedicated" to the fire watch. The Maintenance Supervisor verified the documentation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2011 edition of NFPA 25, by ensuring that sprinkler system is correctly maintained. This deficient practice affects all occupants in this facility with a capacity of 22 and a census of six.

Findings include:

1. Record review on 11/12/2019 at 0900 a.m., of the facility's sprinkler system inspection reports, revealed the facility failed to maintain the fire sprinkler system by assuring the five year internal obstruction assessment had been conducted. The facility provided documentation from the previous five year internal inspection conducted on 8/2014 conducted by Blackhawk. This inspection was outside the five year requirement. The Maintenance Supervisor verified these observations during the survey process.

2. Observation and interview on 11/12/2019 at 2:01 p.m., revealed the facility failed to maintain the sprinkler system in the Sub Basement at the Bottom of the Ramp area. This area contained many low voltage wires and phone lines being supported by the sprinkler pipe. The Maintenance Supervisor verified these observations during 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 22 and a census of six residents at the time of the survey.

Findings include:

Record review on 11/12/2019 at 09:12 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. 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 this during the survey process.

Based on observation and interview, the facility is not assuring the 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, by allowing the passage of smoke. This deficient practice affects residents, staff, and visitors. The facility has a capacity of 22 with a census of six.

Findings include:

Observations and interview on 11/12/2019 at 2:21 p.m., revealed the smoke barrier in the X-Ray Bathroom had a 1/2 inch gap around an escutcheon ring for the sprinkler head. The Maintenance Supervisor verified these observations at the time of the survey process.

Based on observation and interview, it was determined 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, 210.8, by not providing ground-fault circuit-interrupter (GFCI)protection for staff, residents, and visitors. The facility has a capacity of 22 and a census of six.

Findings Include:

1. Observation and interview on 11/12/2019 at 1:21 p.m., revealed the facility failed to maintain the electrical system in the Laundry Room. This room contained an outlet on the west wall under the circut breaker box that did not have ground-fault circuit-interrupter (GFCI) protection. This outlet was within six feet of the washing machine water source. The Maintenance Supervisor verified this observation during the survey process.

2. Observation and interview on 11/12/2019 at 1:42 p.m., revealed the facility failed to maintain the electrical system in the 1st Floor Dining Room Front. This room contained several outlets around the sink that did not have ground-fault circuit-interrupter (GFCI) protection. The Maintenance Supervisor verified this observation during the survey process.

3. Observation and interview on 11/12/2019 at 2:46 p.m., revealed the facility failed to maintain the electrical system in the 3rd Floor Nurse Report Room. This room contained an outlet above the counter top next to the sink that did not have ground-fault circuit-interrupter (GFCI) protection. The Maintenance Supervisor verified this observation 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. 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 22 and a census of six residents at the time of survey.

Findings include:

Record review and interview on 11/12/2019 at 11:25 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct fire drills during varied times. With in the last year the facility had conducted two fire drills at 3:35 p.m. in March and September. The Maintenance Supervisor verified these findings during the survey process.

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. The deficient practice affects all of the smoke compartments throughout the building and all occupants. The facility had a capacity of 22 and a census of six residents at the time of the survey.

Findings include:

1. Record review and interview on 11/12/2019 at 11:51 a.m., revealed the facility was unable to provide documentation of exercising the components of the essential electrical system (EES) main and feeder circuit breakers. Interview of The Maintenance Supervisor revealed the facility had not set up a annual maintenance for these components. The Maintenance Supervisor verified these findings at the time of the survey.

1. Record review and interview on 11/12/2019 at 10:45 a.m., revealed the facility was unable to provide documentation of a weekly check of the belts on the generator. The Maintenance Supervisor verified these findings during the survey process.