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Based on observation and interview, the facility did not provide an enclosed or protected vertical opening in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.1.1 and 8.6., by being unable to show the basement stair enclosure construction was not less than a 1-hour fire resistance rating. This deficient practice could affect all occupants in one of seven smoke zones.

Findings include:

Observation and interview on 10/12/2020 at about 2:03 p.m., revealed the doors and door frame atop of the Basement stair enclosure at the PT Equipment Room area did not contain a fire rated tag or label. Interview of the Maintenance Supervisor revealed the facility did not have any other means to verify the rating of these fire doors, as there is no documentation provided by an inspection or certification service.

The Maintenance Supervisor verified this finding at the time of discovery.

Based on observation and interview, the facility failed to provide a placard for the use of the K-type fire extinguisher in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (Section-10.2.2), 2011 Edition. This deficient practice affects all staff in the Kitchen area.

Findings include:

Observation and interview on 10/12/2020 at about 1:08 p.m., revealed the facility failed to provide a placard at the K-type fire extinguisher located in the Kitchen that states the extinguisher is to be used only after the fixed suppression system has been actuated.

The Maintenance Supervisor verified this observation at the time of the survey process.

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. 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 18 and a census of three residents at the time of the survey.

Findings include:

Interview and record review on 10/12/2020, at about 09:31a.m., revealed the facility 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 phone numbers to the authorities needing to be contacted (State Fire Marshal and Department of Inspection & Appeals) and did not include that the timing of the fire watch tours.
2.) The policy lacked the persons assigned to do fire watch would be dedicated.
3.) The policy did not state the fire watch would be "continuous".


The Maintenance Supervisor verified the documentation at the time of the survey process.

Based on observation and interview, the facility is not providing properly inspected sprinkler pipe in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.2.2, by allowing an external load by material resting or hung from the pipe. This deficient practice does not affect any residents in the Basement of the facility. The facility had a capacity of 18 with a census of three residents at the time of the survey.

Findings include:

1. Observation and interview on 10/12/2020, at about 12:41 p.m., revealed old phone wires were attached to the sprinkler pipe in the Basement Hallway.

2. Observation and interview on 10/12/2020, at about 12:36 p.m., revealed lagging from an overhead steam line was resting on the sprinkler pipe in the Basement Hallway.

The Maintenance Supervisor verified these findings 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. 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 18 and a census of three residents at the time of the survey.

Findings include:

Record review on 10/12/2020 at about 8:54 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.

The Maintenance Supervisor verified the documentation at the time of the survey process.

Based on observation and interview, it was determined the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, 210.8, by not providing ground-fault circuit-interrupter protection for staff, residents, and visitors. This deficient practice would place all occupants in this area at risk for electric shock and or loss of limb. The facility has a capacity of 18 and a census of three.

Findings Include:

1. Observation and interview on 10/12/2020 at about 1:31 p.m., revealed the facility failed to maintain the electrical system in the X-Ray B Sink Room area. This small room contained two outlets within six feet of the sink that did not have ground-fault circuit-interrupter (GFCI) protection. The outlet did not shut off the power when tested.

2. Observation and interview on 10/12/2020 at about 12:11 p.m., revealed the facility failed to maintain the electrical system in the Laundry Room Hallway. This hallway contained a thermostat cover that was broken on the east wall allowing for the exposure of wiring within its assembly.

The Maintenance Supervisor verified this observation during the survey process.

Based on record review and interview, the facility failed to provide an adequate evacuation and relocation plan and procedure in case of fire plan for the evacuation of the building's smoke zones directly affected by fire in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1 and 19.7.2. This deficient practice affects all smoke zones, residents, staff, and visitors. The facility had a capacity of 18 and a census of three residents at the time of the survey.

Findings include:

Record review and interview on 10/12/2020 at about 10:50 a.m. of the facility's Fire plan, revealed the facility did not have a specific or complete smoke compartment evacuation plan. The evacuation plan did not address identifying characteristics of the facility, like the names of the smoke compartments/halls, to distinguish it from universal emergency procedure. The plan failed to describe how to evacuate based on triangulation in proximity to the fire. The plan also did not include adequate detail regarding the extinguishment of fire by failing to address staff awareness of the types, including K, of fire extinguishers. The plan failed to address who would contact the local fire department during a fire. The plan did not address how the transmission of alarms would be administered to the local fire department. The plan did not address how the zones of the building would be prepared for evacuation. This completed plan also needs to be accessible to all staff on all shifts.

The Maintenance Supervisor confirmed the documentation during the survey process.

Based on record review and interview, the facility failed to conduct/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 all smoke compartments and all residents, staff, and visitors. The facility had a capacity of 18 and a census of three residents at the time of the survey.

Findings include:

Record review and interview on 10/12/2020 at about 12:06 p.m., revealed the facility was unable to provide documentation of any receptacle testing or documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Interview of the Maintenance Supervisor revealed the facility has all hospital grade receptacles in patent care areas however documentation has not been created or maintained for these devices.

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