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Based on observation and staff interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants in two of twelve smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 04/28/2015 at 11:05 a.m., revealed the facility failed to maintain the door to Resident Room #123. This door contained a ' kick-down ' or doorstop located at the base of the door that could prevent the door from being closed in an emergency.

2. Observation and interview on 04/28/2015 at 11:20 a.m., revealed the facility failed to maintain the X-Ray corridor door. This door contained a ' kick-down ' or doorstop located at the base of the door that could prevent the door from being closed in an emergency. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that one of eleven smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls 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 11 residents, staff, and visitors in the facility affecting two of twelve smoke compartments. The facility has a capacity of 25 with a census of 11.

Findings include:

Observation and interview on 04/28/2015 at 11:10 a.m., revealed the facility failed to maintain the 100 hall smoke barrier. This smoke barrier contained (3) 3/4 inch conduits with an open center above the lay in tile. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview,the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the twelve smoke compartments in the building. This deficient practice could affect 11 residents, staff and visitors. The facility has a capacity of 25 and a census of 11.

Findings include:

Observation and interview on 04/28/2015 at 11:20 a.m., revealed the facility failed to maintain the Main Entrance Corridor Smoke Barrier doors. These double doors failed to close and positively latch while being tested. The Maintenance Director verified this observation at the time of the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 11.

Findings include:

Review of the facility's fire drill records on 04/28/2015 at 9:55 a.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2014. The facility failed to provide documentation of any fire drills being conducted on the second and third shift, second quarter of 2014. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 11 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observations and interview on 04/28/2015 at 10:00 a.m., revealed the facility failed to maintain the fire alarm system in the Administration Corridor. This corridor contained a smoke detector with in three feet of an air diffuser.

2. Observations and interview on 04/28/2015 at 10:10 a.m., revealed the facility failed to maintain the fire alarm system in the Operating Room Lounge. This room contained a smoke detector with in three feet of an air diffuser.

3. Observations and interview on 04/28/2015 at 10:12 a.m., revealed the facility failed to maintain the fire alarm system in the Operating Room Woman's Locker Room. This room contained a smoke detector with in three feet of an air diffuser.

4. Observations and interview on 04/28/2015 at 10:20 a.m., revealed the facility failed to maintain the fire alarm system in the two (2) Equipment Storage Rooms across from room #152. These rooms contained a smoke detector with in three feet of an air diffuser.

5. Observations and interview on 04/28/2015 at 10:25 a.m., revealed the facility failed to maintain the fire alarm system in the Pharmacy. This room contained a smoke detector with in three feet of an air diffuser.

6. Observations and interview on 04/28/2015 at 10:30 a.m., revealed the facility failed to maintain the fire alarm system in the corridor near the Operating Room Entrance. This corridor contained a smoke detector with in three feet of an air diffuser.

7. Observations and interview on 04/28/2015 at 11:15 a.m., revealed the facility failed to maintain the fire alarm system in Family Room #205. This room contained a smoke detector with in three feet of an air diffuser.

8. Observations and interview on 04/28/2015 at 11:25 a.m., revealed the facility failed to maintain the fire alarm system in the Micro Laboratory. This room contained a smoke detector with in three feet of an air diffuser.

9. Observations and interview on 04/28/2015 at 11:26 a.m., revealed the facility failed to maintain the fire alarm system in the Laboratory. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observations at the time of the survey process.

Based on observation, the facility failed to maintain and test fire extinguishers as required. Three of three fire extinguishers in one of one smoke compartments were affected by the deficient practice. This deficient practice could affect 1 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 11.

Findings include:

Observation and interview of the fire extinguishers on 04/29/2015 at 9:20 a.m., revealed the facility failed to maintain three fire extinguishers in the Williamsburg Family Medical Clinic. These extinguisher were expired in March of 2015. The last annual inspection was conducted by Iowa Fire Equipment in March 2014. The Maintenance director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing all Staff in this room at risk in the event of a fire. The facility had a capacity of 25 and a census of 11.

Findings Include:

1. Observation and interview on 04/28/2015 at 1:10 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #5 contained a standard electrical outlet next to the sink.

2. Observation and interview on 04/28/2015 at 1:12 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #4 contained a standard electrical outlet next to the sink.


3. Observation and interview on 04/28/2015 at 1:14 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #6 contained a standard electrical outlet next to the sink.


4. Observation and interview on 04/28/2015 at 1:17 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #1 contained a standard electrical outlet next to the sink.


5. Observation and interview on 04/28/2015 at 1:20 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #2 contained a standard electrical outlet next to the sink.

6. Observation and interview on 04/28/2015 at 1:25 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #3 contained a standard electrical outlet next to the sink. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and staff interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants in two of twelve smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 04/28/2015 at 11:05 a.m., revealed the facility failed to maintain the door to Resident Room #123. This door contained a ' kick-down ' or doorstop located at the base of the door that could prevent the door from being closed in an emergency.

2. Observation and interview on 04/28/2015 at 11:20 a.m., revealed the facility failed to maintain the X-Ray corridor door. This door contained a ' kick-down ' or doorstop located at the base of the door that could prevent the door from being closed in an emergency. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that one of eleven smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls 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 11 residents, staff, and visitors in the facility affecting two of twelve smoke compartments. The facility has a capacity of 25 with a census of 11.

Findings include:

Observation and interview on 04/28/2015 at 11:10 a.m., revealed the facility failed to maintain the 100 hall smoke barrier. This smoke barrier contained (3) 3/4 inch conduits with an open center above the lay in tile. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview,the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the twelve smoke compartments in the building. This deficient practice could affect 11 residents, staff and visitors. The facility has a capacity of 25 and a census of 11.

Findings include:

Observation and interview on 04/28/2015 at 11:20 a.m., revealed the facility failed to maintain the Main Entrance Corridor Smoke Barrier doors. These double doors failed to close and positively latch while being tested. The Maintenance Director verified this observation at the time of the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 11.

Findings include:

Review of the facility's fire drill records on 04/28/2015 at 9:55 a.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2014. The facility failed to provide documentation of any fire drills being conducted on the second and third shift, second quarter of 2014. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 11 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observations and interview on 04/28/2015 at 10:00 a.m., revealed the facility failed to maintain the fire alarm system in the Administration Corridor. This corridor contained a smoke detector with in three feet of an air diffuser.

2. Observations and interview on 04/28/2015 at 10:10 a.m., revealed the facility failed to maintain the fire alarm system in the Operating Room Lounge. This room contained a smoke detector with in three feet of an air diffuser.

3. Observations and interview on 04/28/2015 at 10:12 a.m., revealed the facility failed to maintain the fire alarm system in the Operating Room Woman's Locker Room. This room contained a smoke detector with in three feet of an air diffuser.

4. Observations and interview on 04/28/2015 at 10:20 a.m., revealed the facility failed to maintain the fire alarm system in the two (2) Equipment Storage Rooms across from room #152. These rooms contained a smoke detector with in three feet of an air diffuser.

5. Observations and interview on 04/28/2015 at 10:25 a.m., revealed the facility failed to maintain the fire alarm system in the Pharmacy. This room contained a smoke detector with in three feet of an air diffuser.

6. Observations and interview on 04/28/2015 at 10:30 a.m., revealed the facility failed to maintain the fire alarm system in the corridor near the Operating Room Entrance. This corridor contained a smoke detector with in three feet of an air diffuser.

7. Observations and interview on 04/28/2015 at 11:15 a.m., revealed the facility failed to maintain the fire alarm system in Family Room #205. This room contained a smoke detector with in three feet of an air diffuser.

8. Observations and interview on 04/28/2015 at 11:25 a.m., revealed the facility failed to maintain the fire alarm system in the Micro Laboratory. This room contained a smoke detector with in three feet of an air diffuser.

9. Observations and interview on 04/28/2015 at 11:26 a.m., revealed the facility failed to maintain the fire alarm system in the Laboratory. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observations at the time of the survey process.

Based on observation, the facility failed to maintain and test fire extinguishers as required. Three of three fire extinguishers in one of one smoke compartments were affected by the deficient practice. This deficient practice could affect 1 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 11.

Findings include:

Observation and interview of the fire extinguishers on 04/29/2015 at 9:20 a.m., revealed the facility failed to maintain three fire extinguishers in the Williamsburg Family Medical Clinic. These extinguisher were expired in March of 2015. The last annual inspection was conducted by Iowa Fire Equipment in March 2014. The Maintenance director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing all Staff in this room at risk in the event of a fire. The facility had a capacity of 25 and a census of 11.

Findings Include:

1. Observation and interview on 04/28/2015 at 1:10 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #5 contained a standard electrical outlet next to the sink.

2. Observation and interview on 04/28/2015 at 1:12 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #4 contained a standard electrical outlet next to the sink.


3. Observation and interview on 04/28/2015 at 1:14 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #6 contained a standard electrical outlet next to the sink.


4. Observation and interview on 04/28/2015 at 1:17 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #1 contained a standard electrical outlet next to the sink.


5. Observation and interview on 04/28/2015 at 1:20 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #2 contained a standard electrical outlet next to the sink.

6. Observation and interview on 04/28/2015 at 1:25 p.m., revealed the facility failed to maintain the electrical system in the Marengo Family Medical Clinic. Patient Room #3 contained a standard electrical outlet next to the sink. The Maintenance Director verified these observations at the time of the survey process.