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Based on record review and staff interview, the facility failed to provide an Emergency Preparedness Plan in accordance with 42 CFR 483.73. This deficient practice affects 8 patients in 19 of 19 zones. The facility has a capacity of 42 and a census of 8.

Findings include:

Record review and interview on 12/10/19 at 10:38 a.m., revealed the facility failed to provide documentation of cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

Administrative Staff A and Maintenance Staff A observed this finding.

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 482.15(b), by failing to develop arrangements with other facilities or providers to receive residents in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. This deficient practice affects all occupants of the facility. The facility had a capacity of 42 and a census of 8 patients at the time of the survey.

Findings include:

Record review and staff interview on 12/10/19 at 10:38 a.m. revealed the facility failed to provide an Emergency Preparedness Plan which includes copies of transfer agreements and arrangements with other facilities to receive patients in the event the facility cannot care for them in an emergency.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to provide documentation of policies & procedures for applying for an 1135 waiver (with contact information for the CMS Regional Office and State Fire Marshal Division). This deficient practice affects all occupants in 19 of 19 zones. The facility has a capacity of 42 and a census of 8.

Findings include:

Record review and interview on 12/10/19 at 10:38 a.m., revealed the facility failed to provide documentation of policies and procedures for applying for an 1135 waiver in the event care is provided at an alternative site.

Maintenance Staff A and Administrative Staff A observed this finding.

Based on record review and interview, the facility failed to provide an Emergency Preparedness Plan in accordance with 42 CFR 483.73. This deficient practice affects 8 patients in 19 of 19 zones. The facility has a capacity of 42 and a census of 8.

Findings include:

Record review and interview on 12/10/19 at 10:38 a.m., revealed the facility failed to provide documentation of a written training and testing program for all new/existing staff members and volunteers.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on observation and interview, the facility did not provide adequate exit signage that is readily visible from any direction of exit access for all exit doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.10.1 and 7.10. This deficient practice affects all occupants of the North Clinic. The facility had a capacity of 42 and a census 8 at the time of the survey.

Findings include:

Observation and interview on 12/10/19 at 1:25 p.m., revealed no illuminated exit signs in the east hall of the North Clinic indicating egress to the west exits.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, 2010 edition. This deficient practice affects staff members in 1 of 19 zones. The facility has a capacity of 42 and a census of 8.

Findings include:

Observations and interview on 12/10/19 at 11:01 a.m., revealed no fire alarm system horn/strobes in the Doctor's Sleep Rooms on 3 West & 2 East.

Maintenance Staff A observed this finding.

Based on record review, observation, and interview, the facility did not provide and maintain smoke detectors in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice affects all occupants in the building. The facility had a capacity of 42 and a census of 8 patients at the time of the survey.

Findings include:

Record review, observation, and interview on 12/10/19, revealed the following deficiencies:

1. At 10:10 a.m., the facility failed to provide documentation of sensitivity testing of the smoke detectors.
2. At 1:36 p.m., the smoke detector in the corridor of the South Clinic near Room 19 was located within 3-feet of a HVAC supply vent.

These deficient practices were confirmed by Maintenance Staff A.

Based on interview and record review, this facility did not assure that a 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 facility. This facility had a capacity of 42 and a census of 8 patients at the time of the survey.

Findings include:

Record review and interview on 12/10/19 at 1:08 p.m., of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 10 hours in a 24-hour period. The policy failed to have the following information included in their policy as required by NFPA 25, 2011 Edition (Chapter 15):

1. The sprinkler system outage policy did not address contacting the Iowa Department of Inspections and Appeals.
2. The sprinkler system outage policy did not address contacting the facility's insurance carrier.
3. The sprinkler system outage policy did not address the determination of the extent & expected duration of the impairment.
4. The sprinkler system outage policy did not address the implementation of a tag impairment system.
5. The sprinkler system outage policy did not address the assembly of all necessary tools and materials on the impairment site.
6. The sprinkler system outage policy did not address system leakage, interruption of water supply, ruptured piping, and equipment failure.
7. The sprinkler system outage policy failed to state the fire watch rounds shall be "continuous" with rounds of the affected areas completed at least every 30 minutes.

Maintenance Staff A & B observed these findings.

Based on observation and interview, the facility did not ensure corridor doors fit tightly within the doorframe to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition. This deficient practice affected all occupants in 2 of 19 smoke zones as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 42 and a census of 8 patients at the time of the survey.

Findings include:

Observation and interview on 12/10/19 at 10:59 a.m., revealed the following deviancies:

1. No latch on the door to the HBO Clean Linen Closet.
2. An accordion door (not smoke tight) to the storage room located next to the Doctor's Sleep Room on 3 West.

Maintenance Staff A confirmed the observation and findings at the time of discovery.

Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.7.1 and 19.7.2. This deficient practice affects all occupants in the facility. This facility had a capacity of 42 and a census of 8 residents at the time of the survey.

Findings include:

Record review and interview on 12/10/19 at 1:03 p.m., revealed the following Fire Safety Plan deficiencies:
1. The Fire Safety Plan failed to address the use of the hood extinguishment system in the Kitchen.
2. The Fire Safety Plan failed to address the preparation of the floors and building for evacuation.
3. The Fire Safety Plan failed to address the use of the different types of fire extinguishers.

Maintenance Staff A observed these findings.

Based on record review and interview, this facility is not maintaining fire 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. This deficient practice affects all occupants in the facility. The facility has a capacity of 42 and a census of 8.

Findings include:

Record review and interview on 12/10/19 at 10:19 a.m., revealed the facility could not provide any documentation of inspection and testing of fire doors located throughout the building (in accordance with NFPA 80).

Maintenance Staff A observed this finding.

Based on record review and interview, this facility did not maintain the diesel emergency generator by maintaining complete monthly documentation as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.1, 8.3.4, & 8.4.2. The deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This deficient practice affects 8 patients in 19 of 19 zones. This facility had a capacity of 42 and a census of 8 patients at the time of the survey.

Findings include:

Record review and interview conducted on 12/10/19 at 9:56 a.m., of the facility's generator inspection testing and maintenance records revealed:

1. No meter readings on the generator run log.
2. No indication of the percentage of nameplate the generator is running at during the load tests on the generator run log.
3. No meter start and stop times on the generator run log.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain electrical apparatus in accordance with National Fire Protection Association (NFPA) 70, 2011 edition. This deficient practice affects all occupants in 1 of 19 zones. The facility has a capacity of 42 and a census of 8.

Findings include:

Observations and interview on 12/10/19, revealed the following deficiencies:

1. At 11:31 a.m., an electrical cube adaptor in the Laundry Breakroom.
2. At 1:45 p.m., a battery charger on an electrical multiplug strip in the room next to the Computer Room in the South Clinic.

Maintenance Staff A observed this finding.

Based on observation and interview, the facility did not store oxygen tanks in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 11.6.5, by ensuring empty and full tanks were adequately separated and labeled to prevent confusion when choosing tanks in an emergency. This deficient practice affected all occupants in 1 of 19 zones. This facility had a capacity of 42 and a census of 8 patients at the time of the survey.

Findings include:

Observation and interview on 12/10/19 at 11:46 a.m., revealed the full oxygen cylinders were not separated from the empty oxygen cylinders in the Oxygen Storage Room in Technical Services.

Maintenance Staff A observed this finding.