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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 27 with a census of 11.

Findings include:

Observation on 08/25/2020 at 1:21 p.m., revealed the fire alarm breaker, located on the first floor across from Maternity Ward, was not secured with a mechanical lock.

The Director of Maintenance verified this observation during 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 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 27 and a census of 11 residents at the time of the survey.

Findings include:

Record review and interview on 08/25/2020 at 10:52 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Interim Life Safety Management Policy, revealed the policy language failed to state the following required statements: fire watch designee is to be dedicated and continuous, and that all portions of the facility will be checked at least once every 30 minutes, the policy did not instruct facility personnel to contact the local fire department, Iowa Department of Inspections and Appeals, or the insurance carrier at the beginning or conclusion of the fire watch or include any procedures on how to conduct a fire watch, along with the provided phone numbers for each.

Maintenance Staff A revealed the findings 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 27 and a census of 11 residents at the time of the survey.

Findings include:

Record review on 08/25/2020 at approximately 10:44 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 and Maintenance Staff B 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, 6.1.3.4, by ensuring all portable, non-wheeled fire extinguishers are installed on a hanger, in a supplied or listed bracket, or in cabinets or wall recesses. This deficient practice affects one fire extinguisher in one of 11 smoke compartments and could affect staff in the Kitchen. This facility had a capacity of 46 and a census of 40 consumers at the time of the survey.

Findings include:

Observation on 08/25/2020 at 11:41 a.m., revealed the Class K fire extinguishers located in the Kitchen did not reveal a proper placard describing its intended use above each extinguisher; that the K type fire extinguisher was to be used for grease or oil fires. Maintenance Staff B stated he was unaware of the requirement, and that he had never been advised of this during all the times he's worked here.

Maintenance Staff B verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects one of three smoke compartments and all residents, staff, and visitors. The facility had a capacity of 27 and a census of 11 residents at the time of the survey.

Findings include:

Record review on 08/25/2020 at approximately 11:30 a.m., revealed the facility was unable to provide documentation of non-hospital-grade receptacle testing at patient bed locations throughout the facility. Interview of the Administrator revealed the facility was not aware of this testing requirement.

The Maintenance Director confirmed this finding at the time of the survey.

Based on record review, observations, and interview, the facility 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; 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 27 and a census of 11 patients at the time of the survey.

Findings include:

1. Record review and interview on 08/25/2020 at 11:01 a.m., revealed the facility failed to maintain proper documentation of weekly inspection testing for the facility's emergency generators. The facility had not included BELTS/HOSES for either of the facility's two generators during any weekly inspection. The facility also had not included documentation of the transfer switch being operated and the time to transfer for either of the facility's two generators during the 30 minute monthly load tests.

2. Record review and interview also revealed the facility was conducting required inspections and exercising of the components of the essential electrical system (EES) main and feeder circuit breakers, but was unable to provide record of exercising or explain the facility's process including mechanically tripping and resetting the main and feeder circuit breakers.

The Director of Maintenance acknowledged these findings during the survey process.