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Based on observation and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. This deficient practice affects one light fixture in the Old OR Room of the facility. The facility has a capacity of 25 and a census of 2.

Findings include:

Observation on 04/19/2023 at 3:58 p.m., revealed the battery backup emergency light located on the east wall in the Old Operating Room failed to illuminate when tested. 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 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 25 and a census of 2 residents at the time of the survey.

Findings include:

1. Record review and interview on 04/19/2023 at 4:47 p.m. of the fire watch procedures for a fire alarm system outage in the facility's Life Safety Management Policy, revealed the intervals at which security personnel were directed to perform fire watches to check for fire at least every 30 minutes. This this fire watch designee is to be dedicated and the firewatch is to be continuous. The Administrative Staff Member verified the documentation at the time of the survey process.

2. Record review and interview on 04/19/2023 at 4:47 p.m. of the fire watch procedures for a fire alarm system outage in the facility's Fire Watch - Fire Alarm policy, revealed the policy did not instruct facility personnel to contact the Iowa Department of Inspections and Appeals (DIA; Authority Having Jurisdiction), at the beginning or conclusion of the fire watch. The Administrative Staff Member verified the documentation at the time of the survey process.

Based on observation and interview, the facility failed to inspect and maintain the automatic sprinkler system within the facility by assuring the sprinkler system gauges are replaced or tested every five years in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.3.2.1. This deficient practice could affect all smoke compartments and occupants of the facility. The facility had a capacity of 25 residents and a census of 2 at the time of the survey.

Findings include:

1. Observation and interview on 04/19/2023 at 3:45 p.m., of the facility's sprinkler system revealed the two gauges on the dry sprinkler system riser in the Dry Sprinkler Room/Closet was dated 10/2014. No other documentation was provided showing the gauge had been tested as required. Interview of the Maintenance Supervisor revealed he was employed for approximately two years at this facility and did not realize the sprinkler company had not replaced these valves. The Maintenance Supervisor verified this finding at the time of the survey.

2. Observation and interview on 04/19/2023 at 4:15 p.m., of the facility's sprinkler system revealed the two gauges on the wet sprinkler system riser in the Sprinkler Riser Room was dated 10/2014. No other documentation was provided showing the gauge had been tested as required. Interview of the Maintenance Supervisor revealed he was employed for approximately two years at this facility and did not realize the sprinkler company had not replaced these valves. The Maintenance Supervisor verified this finding at the time of the survey.

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 25 and a census of 2 residents at the time of the survey.

Findings include:

Record review on 04/19/2023 at 4:42 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 and was missing the following information:

1. Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

2. List contact numbers for State Fire Marshal, Department of Inspections and Appeals, Insurance Company and Local Fire Department.

3. The fire watch designee is dedicated and continuous.

Administrative Staff Member verified the documentation at the time of the survey process.

Based on observation and testing, the facility did not ensure fire rated smoke barriers doors were maintained and positive latching in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 8.3.3.1 and 4.6.12.3 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition. This deficient practice affected two smoke zones in the facility. This facility had a capacity of 25 and a census of 2 patients at the time of the survey.

Findings include:



1. Observation and testing on 04/19/2023 at 3:12 p.m., revealed the double fire-rated barrier doors in the Hallway near the Purchasing Office had an excessive amount of space between the doors when closed. In the event of a fire, this spacing between fire doors would allow the passage of flame and smoke between zones.

2. Observation and testing on 04/19/2023 at 3:20 p.m., revealed the north leaf of the double fire-rated barrier doors in the Hallway near the Public Health Office failed to close and positively latch within the door frame.

The Maintenance Supervisor confirmed these findings at the time of discovery.

Based on record review and interview, the facility is not ensuring evacuation drills are conducted at least quarterly for each shift of personnel and under varied conditions in accordance with the Code of Federal Regulations (CFR), 42 CFR 483.470(i) Standard: Evacuation drills. This deficient practice affects all occupants, as it has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 residents and a census of 2.

Findings include:

Record review and interview on 04/19/2023 at 3:05 p.m. of the facility's fire drill documentation, revealed the facility failed to provide documentation that fire drills were conducted during the second shift (7 p.m.- 7 a.m.) for the second quarter of 2022, the second shift for the third quarter of 2022 and the second shift for the fourth quarter of 2022. Interview with the administrator in charge of these drill revealed she had just started this assignment at the beginning of 2023 and had inherited a policy that had been neglected.

The Maintenance Supervisor and this Administrative Staff member verified the documentation during the survey process.

Based on record review and interview, the facility failed to maintain complete documentation of the inspections, exercising, and operation of the emergency generator power supply and/or to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4 and 8.3.8 respectively. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

2. Record review on 04/19/2023 at 4:29 p.m., revealed the facility could not provide any documentation for the generator weekly visual inspections. Interview of Maintenance Supervisor revealed he was unaware of this weekly visual inspection requirement in addition to the monthly load testing .

The Maintenance Supervisor confirmed this finding during the survey.

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. The facility had a capacity of 25 with a census of 2 residents at the time of the survey.

Findings include:

Observation on 04/19/2023 at 3:58 p.m., revealed the Old Whirlpool Room located on the upper level of this facility contained two full cylinders of oxygen stored in this room that were not organized with any separation or provided labels designating empty or full.

The Maintenance Supervisor verified this observations during the survey.