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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, 482.1.5, by failing to incorporate policies and procedures in its emergency plan describing the facility's role under a waiver in accordance with Social Security Act, Section 1135, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 2 patients at the time of the survey.

Findings include:

Record review and interview on 10/22/20 at 1:08 p.m., revealed the facility's emergency preparedness policies and procedures did not specifically address the facility's role in emergencies where the Health and Human Services Secretary declares a public health emergency. The emergency preparedness plan failed to demonstrate the facility's general awareness of the 1135 process, including the following:

1) Knowledge of how to request a waiver and who to contact (contact information) in the event an 1135 waiver needs to be requested

2) The circumstances when an 1135 waiver might be granted based on the risk analysis

3) How they would operate under and outline the responsibilities during the duration of the waiver period

4) How they would plan jointly on issues related to staffing, equipment, and supplies

Administrators A, B and C verified this finding during the survey process.

Based on observations and interviews, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2. This deficient practice could affect all patients, staff, and visitors in the Basement. The facility had a capacity of 25 patients and a census of 2 at the time of the survey.

Findings include:

1. Observations and interview on 10/22/20 at 11:47 a.m., revealed the facility failed to maintain the one hour walls in IT Closet #5 in the Basement. This room contained a large conduit with IT wires running through it that was not properly sealed. It appeared that the fire putty had partially slipped off of this conduit.
2. Observations and interview on 10/22/20 at 11:50 a.m., revealed two large water lines in the IT Closet by the boiler room that contained gaps (approximately 1 inch in size) around them.
3. Observations and interview on 10/22/20 at 11:55 a.m., revealed a one inch hole above the strobe and fire extinguisher by the door and a gap around a conduit in Fan Room 12.

The Maintenance Director confirmed these observations during the survey.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 17.7.4.1, which requires that smoke detectors not be located in a direct airflow or closer than three feet from an air supply diffuser or return air opening. This deficient practice affects all occupants in the facility, as smoke detectors located within three feet of a direct air flow, air supply diffuser, or air return opening can impede the operation of the detector. This facility has a capacity of 25 and a census of 2.

Findings include:

1. Observation and interview on 10/22/20 between 8:00 and 11:00 a.m. revealed smoke detector M2-94 located in the corridor outside the "Visiting Specialists" office was less than 36" from an air supply diffuser.
2. Observation and interview on 10/22/20 between 8:00 and 11:00 a.m. revealed smoke detector M2-98 located in the "Back Draw Room" in the lab was less than 36" from an air supply diffuser.
3. Observation and interview on 10/22/20 between 8:00 and 11:00 a.m. revealed smoke detector M2-200 located in the corridor outside the "UR/QA" office was less than 36" from an air supply diffuser.
4. Observation and interview on 10/22/20 between 8:00 and 11:00 a.m. revealed a smoke detector located the "Human Resource Specialist" office was less than 36" from an air supply diffuser.
6. Observation and interview on 10/22/20 between 8:00 and 11:00 a.m. revealed two smoke detectors located the IT offices were less than 36" from an air supply diffuser.
7. Observation and interview on 10/22/20 between 8:00 and 11:00 a.m. revealed smoke detector M1-012 located the Store Room off of the conference center was less than 36" from an air supply diffuser.

Maintenance Staff verified these findings during the survey process.

Based on interview and record review, the facility did not assure that an adequate policy is in place regarding the procedures to be taken in the event that the fire alarm 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 written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This deficient practice affected all occupants of the building in this facility with a capacity of 25 and a census of 2.

Findings include:

Record review on 10/22/20, at 12.59 p.m., revealed the fire watch procedures from the Director of Patient Care 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 contacting the LeMars Fire Department and Department of Inspection & Appeals along with their phone numbers.
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" and all portions of the affected area would be checked at least every 30 minutes.


This policy was combined with the outage policy for the sprinkler system and was last updated/changed on 05/01/11.

Administrative Staff A, B, and C confirmed the findings during the exit conference.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage, installed in the correct orientation and assuring that the the sprinkler system is operating properly. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all patients, staff, and visitors who may be in the Dining Room. The facility had a capacity of 25 and a census of 2 at the time of the survey.

Findings include:

1. Observation and interview on 10/22/20 at approximately 9:22 a.m., revealed the facility failed to maintain the sprinkler system in the Store Room across from the multi-purpose room where there was a missing escutcheon ring.
2. Observation and interview on 10/22/20 at approximately 10:05 p.m., revealed the facility failed to maintain the sprinkler system in the Kitchen. Multiple sprinkler heads contained lint and dust throughout.
3. Observation and interview on 10/22/20 at approximately 11:45 a.m. revealed the following deficiencies on the 09/22/20 inspection report by Continental that have not been addressed. Maintenance Supervisor stated that they were supposed to be receiving a bid for the repairs:
a) Have the backflow devices passed backflow test? No, #2 check failed to hold minimum of 1 PSI.
b) 6" Fire Line--Fail. #2 check failed to hold a minimum of 1 PSI.

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 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 patients at the time of the survey.

Findings include:

Record review on 10/22/20 at 1:08 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. Assigning an Impairment Coordinator.
2. Determining the extent and expected duration of the impairment.
3. Submit recommendations to management.
4. When the system is out of service for more than 10 hours in a 24 hours period, the Impairment Coordinator shall arrange for one of the following:
A) evacuation of the building or portion of the building affected by the outage
B) an approved fire watch
C) establishment of a temporary water supply
D) establishment and implementation of an approved program to eliminate potential ignition
sources and limit the amount of fuel available to the fire
5. Notifying the fire department.
6. Notifying insurance carrier, the alarm company, property owner or designated representative and other AHJ's.
7. Notifying the supervisors in the areas that are affected by the outage.
8. 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.
9. All necessary tools and materials have been assembled on the impairment site.
10. Address the emergency impairments to include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
11. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented.
12. 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.
13. Supervisors have been advised that protection is restored.
14. The fire department has been advised that protection is restored.
15. The insurance carrier, alarm company, and Iowa DIA have been advised that protection is restored.
16. The impairment tag has been removed.

This policy was combined with the outage policy for the fire alarm system and was last updated/changed on 05/01/11.

Administrative Staff A, B and C 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 patients, staff, and visitors in the affected zone. This facility has a capacity of 25 with a census of 2.

Findings include:

1. Observation and interview on 10/22/20 at 8:36 a.m., revealed the door to Patient Room 8 did not close and latch properly when tested.
2. Observation and interview on 10/22/20 at 8:56 a.m., revealed the door to the Clinical Coordinators Office did not close and latch properly when tested.
3. Observation and interview on 10/22/20 at 8:59 a.m., revealed the door to the Utility Room off of OB would not close without it being pulled. This door was catching on the floor.

The Maintenance Director confirmed these observations during the survey process.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility had a capacity of 25 and a census of 2 patients at the time of survey.

Findings include:

Record review and interview on 10/22/20 at 7:58 a.m. of the facility's fire drill documentation, revealed only two fire drills conducted for the last 12 months. They are dated 02/27/20 (no time given) and 11/07/19 at 1:34 p.m. Maintenance Staff A thought there had to only be one drill per quarter and just recently realized different. He thought that he'd done more than the two listed but was unable to locate any documentation to verify this.

Based on record review and interview, this facility is not assuring that fire doors close and latch properly. These fire and/or smoke door assemblies in openings are required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects all patients, staff, visitors. This facility had a capacity of 25 and a census of 2 patients at the time of the survey.

Findings include:

1. Observation on 10/22/20 between 8:00 and 11:00 a.m. revealed the fire door located by the Lab did not close and latch properly when tested.
2. Observation on 10/22/20 between 8:00 and 11:00 a.m. revealed the fire door located by Speech Therapy did not close and latch properly when tested.
3. Observation on 10/22/20 between 8:00 and 11:00 a.m. revealed the fire door located by Room 4 did not close and latch properly when tested.
4. Observation on 10/22/20 between 8:00 and 11:00 a.m. revealed the fire door located by the Dr's Lounge did not close and latch properly when tested.

Maintenance Staff A confirmed the documentation at the time of the survey.

Based on record review, observations, 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, failed to maintain complete documentation of the inspections, tests, exercising, and operation of the emergency generator power supplies as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4; did not ensure the emergency generators for the building were properly equipped with a remote manual stop mechanism in accordance with NFPA Standard 110, 2010 edition, 5.6.5.6; could not provide documentation showing the emergency generator power supplies were exercised as required by NFPA Standard 110, 2010 edition, 8.4.2; and failed to maintain and test essential electrical system (EES) circuitry as required by NFPA Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. These deficient practices affect all smoke compartments of the building and all occupants. The facility had a capacity of 25 and a census of 2 patients at the time of the survey.

Findings include:

1.) Record review and interview on 10/22/20 at 11:55 p.m., revealed the facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers. Interview of Maintenance Staff A stated he was unaware of this requirement.

2.) Record review and interview on 10/22/20 at 11:59 a.m., revealed the facility failed to maintain proper documentation of the weekly inspections for the facility's emergency generators. The facility failed to include checking belts and hoses during the weekly generator inspections.