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Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 21 residents, staff and visitors in this smoke compartment. The facility has a capacity of 21 and a census of 6.

Findings include:

Observation and interview on 11/8/2022 at 10:26 a.m., revealed the facility failed to maintain the Fire Alarm System in the Emergency Room Waiting Area. This room contained a smoke detector within three feet of an air return. The Maintenance Director verified this observation at the time of the survey process.

Based on interview and record review, the facility did not provide and maintain complete documentation or provide 100% semi-annual testing of the fire alarm system as required by NFPA 72. This deficient practice of not providing complete and verifiable documentation of the inspection, testing, and maintenance of the fire alarm system does not ensure proper operation and prompt repair affecting all occupants in the facility. The facility has a capacity of 21 with a census of 6.

Findings include:

Based on observations and record review on 11/8/2022 at 12:30 p.m., revealed the facility failed to maintain the fire alarm system at the Ackley Provider Based Clinic. The facility could not provide documentation that the fire alarm system has been inspected semi-annually in the past twelve months. A review of the facilities records revealed the Fire Alarm was being inspected annually. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2011 edition of NFPA 25, by ensuring that sprinkler heads have an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This could effect 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 occupants in this facility with a capacity of 21 and a census of 6.

Findings include:

1. Observation and interview on 11/8/2022 at 11:31 a.m., revealed the facility failed to maintain the sprinkler system in Physical Therapy Exam Room #3. This room contained one sprinkler heads without an escution ring. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 11/8/2022 at 10:14 a.m., revealed the facility failed to maintain the sprinkler system in the Materials Management Room. This room contained communications wire taped to the sprinkler pipe along the ceiling near the south end of the room . The Maintenance Director verified this observation at the time of the survey process.


3. Observation and interview on 11/8/2022 at 10:28 a.m., revealed the facility failed to maintain the sprinkler system in the Ambulance Entry. This room contained communications wire taped to the sprinkler pipe along the west wall near the double doors. The Maintenance Director verified this observation at the time of the survey process.



4. Observation and interview on 11/8/2022 at 10:35 a.m., revealed the facility failed to maintain the sprinkler system above the lay in tile of the corridor diagonal wall of the Emergency Room. This corridor contained ceiling grid anchors attached to the sprinkler pipe above the lay in tile. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, affecting one staff in this room. The facility had a capacity of 21 and a census of 6.

Findings Include:

Observation and interview on 11/8/2022 at 11:20 a.m., revealed the facility failed to maintain the electrical system in the Patient Access Manager's Office. This room contained a surge protector supplying electrical power to a fan. The Maintenance Director verified this observation at the time of the survey process.