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Based on record review and interview, this facility is not providing fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2 by failing to inspect and test fire and/or smoke door assemblies annually. This deficient practice affects all residents, staff, and visitors. This facility had a capacity of 25 and a census of five.

Findings include:

Record review and interview on 03/04/2020 at 10:43 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. These 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. The Maintenance Supervisor verified this through record review at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects the first floor utility area. This deficient practice could affect staff, residents and visitors in the facility. The facility has a capacity of 25 and a census of five.

Findings include:

Observation and interview on 03/04/2020 at 1200 p.m., revealed the facility failed to separate the First Floor Utility Room from the Laundry Chute. The Laundry Chute door had parts missing disabling it from being able to close and latch. The Maintenance Supervisor verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to install, test, and maintain the fire alarm system within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice could affect all occupants within the facility. The facility had a capacity of 25 residents and a census of five.

Findings include:

1. Record review on 03/04/2020 at 08:54 a.m., of the fire alarm inspection forms revealed the following: there was not a complete device list provided. According to the facility's fire alarm inspection and testing reports, 100% of the fire alarm system was not tested, and the documentation did not include all of the required testing and information required by NFPA 72. Items missing from the fire alarm testing reports include Damper testing, door hold open devices, and horn strobes. The Maintenance Supervisor verified this during the survey process.

2. Observation and interview on 03/04/2020 at 1:21 p.m., revealed Smoke detector D72 was not properly secured in the Therapy and Kitchen Hallway. Detector D72 was hanging by its wiring only, this detector was not properly secured to the tiles of the ceiling. The Maintenance Supervisor verified this finding during 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 25 and a census of five residents at the time of the survey.

Findings include:

Record review on 03/04/2020, at 11:39 a.m., revealed the fire alarm outage policy did not have a complete policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in a 24-hour period. The policy failed to include the following:

1.) The policy failed to include phone numbers of DIA.
2.) The policy lacked that the persons assigned to do fire watch would be "dedicated".
3.) The policy did not state the fire watch would be "continuous".

The Maintenance Supervisor verified these findings during 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. The facility had a capacity of 25 with a census of five residents at the time of the survey.

Findings include:

1. Observation and interview on 03/04/2020 at 12:45 p.m., revealed a wire attached to the sprinkler pipe north of the Nurses Station above the double doors

2. Observation and interview on 03/04/2020 at 12:50 p.m., revealed a wire attached to the sprinkler pipe in the West Side OTC above the double doors.

3. Observation and interview on 03/04/2020 at 10:07 a.m., revealed the facility missed the first quarterly sprinkler inspection for 2020.

The Maintenance Supervisor verified this during the survey process.
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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 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 25 and a census of five residents at the time of the survey.

Findings include:

Record review on 03/04/2020 at 11:15 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. A tag impairment system has been implemented.
2. All necessary tools and materials have been assembled on the impairment site.
3. Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
4. 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) The fire department has been advised that protection is restored.
(3) The insurance carrier, alarm company, and Iowa DIA have been advised that protection is restored.
(4) The impairment tag has been removed.

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

Based on observations and interview, the facility is not ensuring resident room doors, office doors, and other ancillary area doors to the corridor resist the passage of smoke in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.6.3.1. This deficient practice would not prevent the spread of smoke and could affect all residents, staff, and visitors in the affected areas. This facility has a capacity of 25 with a census of five.

Findings include:

1. Observation and interview on 03/04/2020 at 12:21 p.m., revealed Resident Room door 115 failed to latch properly while closed with in its frame. The doors latching device would not engage the door frame.

2. Observation and interview on 03/04/2020 at 12:23 p.m., revealed the Sleep Lab Corridor door in the West side OTC area failed to close and latch properly when tested.

3. Observations and interview on 03/04/2020 at 12:25 p.m., revealed the West side OTC Outpatient Treatment Center Room door #101 Failed to properly latch when tested .

The Maintenance Supervisor verified these observations during the survey process.

Based on observation and interview, the facility is not assuring that all 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, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. This deficient practice could affect all staff, residents and visitors in the facility. The facility has a capacity of 25 with a census of five.

Findings include:

1. Observations and interview on 03/04/2020 at 12:47 p.m., revealed the smoke barrier in the Boiler Room had several large holes and many penetrations around several pipes in the walls and ceiling areas. The Boiler Room contains the facilities natural gas boiler units. The Maintenance Supervisor verified these observations at the time of the survey process.

2. Observations and interview on 03/04/2020 at 1:05 p.m., revealed The West Side OTC two hour wall above the double doors had many holes larger than one inch diameter. Interview with the Maintenance Supervisor revealed these holes were created during the construction of the new oxygen piping.

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. The facility has a capacity of 25 and a census of five.

Findings Include:

1. Observation and interview on 03/04/2020 at 12:13 p.m., revealed the facility failed to maintain the electrical system in the South Wing. The South Wing had two open junction boxes above door 1924. These two junction boxes had exposed 12 ga wires. The Maintenance Supervisor confirmed this observation during the survey process.

2. Observation and interview on 03/04/2020 at 12:48 p.m., revealed the facility failed to maintain the electrical system in the Boiler Room. This space had an open junction box on the west wall with several 12 ga wires exposed. The Maintenance Supervisor verified this observation at the time of the survey.

3. Observation and interview on 03/04/2020 at 12:35 p.m., revealed the facility failed to maintain the electrical system North of the Nurses Station. Above the double doors north of the Nurses Station one junction box had several 12 ga wires exposed. The Maintenance Supervisor verified this observation at the 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 smoke zones, residents, staff, and visitors. The facility had a capacity of 25 and a census of five residents at the time of the survey.

Findings include:

Record review and interview on 03/04/2020 at 11:20 a.m. of the Facilities Documentation, revealed the facility did not have a documented Fire Safety Plan available for review. The Maintenance Supervisor confirmed this finding during the survey process.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing 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 all residents, staff, and visitors. The facility had a capacity of 25 and a census of five residents at the time of the survey.

Findings include:

Record review and interview on 03/04/2020 at 11:18 a.m., revealed the facility was unable to provide documentation of any receptacle testing or documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Interview of The Maintenance Supervisor revealed the facility had no documentation of testing of any receptacles with in the facility. 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. The deficient practice affects all of the smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of five residents at the time of the survey.

Findings include:

1. Record review and interview on 03/04/2020 at 13:30 p.m., revealed the facility was unable to provide documentation of inspection and exercising of the components of the essential electrical system (EES) main and feeder circuit breakers. Interview of the Plant Operations Manager revealed an annual program to test the facilities main and feeder breakers has not been established therefore No documentation of inspection or exercising could be observed. Plant Operations Manager confirmed this finding at the time of the survey.

2. Record review and interview on 03/04/2020 at 09:18 a.m., revealed the facility was unable to provide documentation for 4-hour continuous under load testing within the past 36 months for the facility's Level 1 diesel powered emergency generator. The Plant Operations Manager verified this observation at the time of the survey process.

3. Record review and interview on 03/04/2020, at 11:37 a.m., revealed the facility failed to conduct a load test during the month of October due to construction at the facility. The Maintenance Supervisor verified this observation during the survey process.

4. Record review and interview on 03/04/2020, at 11:16 a.m., revealed the facility failed to conduct weekly checks from 09/23/2019 - 11/21/2019. The Maintenance Supervisor verified this observation during the survey process.

Based on observation and interview, the facility did not provide a proper storage of oxygen cylinders in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.3.2.3 and 11.6.5 by failing to separate oxygen from combustibles or materials and segregate and label empty cylinders from full cylinders, respectively. This deficient practice affects any residents, staff, and visitors in the Med Surgery area. The facility had a capacity of 25 with a census of five residents at the time of the survey.

Findings include:

Observation and interview on 03/04/2020 at 12:01 p.m., revealed an Equipment Room within the Med Surg area was being used as a storage room for oxygen tanks. Within this Equipment Room oxygen tanks were not secured in areas labeled as full or empty. The Maintenance Supervisor verified this observation during the survey process.