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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, 42 CFR 483.475(b)(8) [ICF]/ 483.73(b)(8) [LTC], 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 6 residents at the time of the survey.

Findings include:

Record review and interview on 08/27/2019 at 11:20 a.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; and

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

The Maintenance Supervisor and the Facility Services Director verified this finding during the survey process.

Based on record review and interview, the facility failed to document periodic testing of the annual 90 minute emergency lighting equipment in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.2.9.1 and 7.9.3. This deficient practice affects light fixtures in the Level 1- Acute facility, the Boiler Room, and the Generator Room and approximately 20 residents and staff. The facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings include:

Record review on 08/27/2019 at 10:05 a.m., revealed the facility was unable to provide documentation of annual 90 minute functional testing for any battery backup emergency light fixture throughout the building. Interview of Maintenance Staff A revealed the facility had conducted periodic testing of emergency lighting fixtures but had not maintained any records of the testing. The last documented 90 minute annual test was conducted in April of 2019.

Maintenance Staff A confirmed these findings during the survey process.

Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with 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, 10.5.5.3 by ensuring the fire alarm dedicated branch circuit(s) be mechanically protected. This deficient practice affects all occupants of the building, including clients, staff, and visitors. This facility has a capacity of 25 with a census of 6.

Findings include:

Observation on 08/27/2019 at 11:36 a.m., revealed the fire alarm breaker, located in electrical Panel LLSI Circuit #42 in the East Zone Fire Panel Room, was not secured with a mechanical lock.

Maintenance Staff A verified this observation during the survey.

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 6 residents at the time of the survey.

Findings include:

1. Record review and interview on 08/27/2019 at 9:50 a.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 local fire department, Iowa Department of Inspections and Appeals (DIA; Authority Having Jurisdiction), or the insurance carrier at the beginning or conclusion of the fire watch or include any procedures for how to conduct a fire watch. The fire department and State Fire Marshal's Office phone numbers were listed separately at the very bottom of the page. The Iowa Department of Inspections and Appeals name and phone number was not listed at the time of the survey. The Maintenance Staff A verified the documentation at the time of the survey process.

2. Record review and interview on 08/27/2019 at 9:50 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Fire Alarm System Shutdown policy, revealed the policy did not state that the employee assigned to the fire watch shall be trained in fire prevention, as required. The Maintenance Staff A verified the documentation at the time of the survey process.

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 and shall be installed in the correct orientation. 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 residents, staff, and visitors who may be in the Kitchen. The facility had a capacity of 25 and a census of 6 at the time of the survey.

Findings include:

Observation and interview on 08/27/2019 at 12:06 p.m., revealed the facility failed to maintain the sprinkler system located in the Kitchen. One sprinkler head located above the prepping table contained lint and dust throughout.

Maintenance Staff A verified this observation 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 6 residents at the time of the survey.

Findings include:

Record review on 08/27/2019 at 9:45 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. Assigning an impairment coordinator.

2. 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.

3. All preplanned impairments shall be authorized by the impairment coordinator, who shall verify the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(6) The insurance carrier has been notified and its phone number.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented.
(9) All necessary tools and materials have been assembled on the impairment site.

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

5. 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) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The insurance carrier, alarm company, and Iowa DIA have been advised that protection is restored.
(5) The impairment tag has been removed.

Maintenance Staff A verified the documentation at the time of the survey process.

Based on observation and interview, the facility failed to install portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 2010 edition, 6.1.3.8.1 by ensuring the top of the fire extinguisher is not more than five feet above the floor. This deficient practice affects one fire extinguisher in one of four smoke compartments and could affect all residents, staff, and visitors. This facility has a capacity of 25 and a census of 6.

Findings include:

Observation and interview on 08/29/2019 at 12:07 p.m., revealed the top of the fire extinguisher in the Kitchen near the dish washer was mounted more than five feet from the floor.

Maintenance Staff A confirmed this observation during the survey process.

Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments, are smoke resisting and are positive latching as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. This deficient practice affected approximately 15 occupants in one of four smoke zones, as the door would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings include:

Observation on 8/27/19, at 12:08 p.m., revealed a kick down device installed on the Kitchen door leading to the cafeteria.

Record review of the facility layout showed this door protected one of four smoke zones, one of which contains the main dining room and kitchen.

Maintenance Staff A confirmed the finding at the time of discovery.

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 6 residents at the time of the survey.

Findings include:

Record review and interview on 08/27/2019 at 10:30 a.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 revealed many of the facility's breakers had been periodically tested, but no documentation of inspection or exercising had been maintained. Maintenance Staff A confirmed this finding at the time of the survey.

Based on record review and interview, the facility failed 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, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 08/27/2019 at 10:15 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel. The last documented diesel fuel quality test was conducted in August of 2018.

Maintenance Staff A and confirmed these findings at the time of the survey.