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Based on observation and interview, the facility is not providing a firewall with a two-hour rating between the patient area and the large mechanical room. This deficient practice would affect all occupant including staff, visitors and residents. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Observations and interview on 8/26/14, revealed the door from Mechanical Room 676 into the hospital did not close and latch properly when tested. According to facility layout, this is a two hour fire wall. Maintenance Staff A verified this observation.

Based on observation and interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly in their frames. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

1. Observation and interview on 8/26/14, revealed the Office door did not latch properly when tested.
2. Observation and interview on 8/26/14 revealed the Supply Room door was being propped open with a wedge.

Based on observation and interview, the facility failed to maintain the fire doors to close and resist the passage of smoke. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

1. Observation and interview on 8/26/14, reveled the fire door located by Lab 254 did not close when tested.
2. Observation and interview on 8/26/14, revealed the fire door located by Waiting Area 202 did not close and latch properly when tested.

Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility failed to test the emergency egress lighting as required. This deficient practice affects all occupants of the building. This facility has a capacity of 25 patients and a census of 7.

Findings include:

1. Observation, interview and record review on 8/26/14, revealed the absence of documentation to verify that 30 second monthly tests are being performed on the five emergency lights located throughout the building. The documentation showed that the 30 second test was performed in the following months for the last 12 months: January, April, May 2014 and September and October 2013.
2. Observation, interview and record review on 8/26/14, revealed the absence of documentation to verify that a 90 minute annual test has been performed within the last 12 months on one of five emergency lights (located in the Generator Hall).


Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain illuminated exit signs in proper working order. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Observations and interview on 8/26/14, revealed the exit signs in the following areas did not operate properly when tested: corridor outside PT, to stairway by elevator, by classroom, and at the top of the stairs on the east side of building going to the exterior exit. (All located at the clinic at 111 South 5th St., Mapleton).

Based on record review and staff interview, the facility is not conducting fire drills at varying times on each shift as required. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 residents and a census of 7.

Findings include:

Record review and staff interview on 8/26/14, revealed the facility failed to vary the times of the fire drills on each shift. On 1st shift, three of the four drills were performed within the same 30 minutes. On 2nd shift, all four drills were performed within the same 15 minutes. And on 3rd shift, all four drills were performed within a 30 minute time frame. Maintenance Staff A verified these observations.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed with direct airflow; not closer than three feet to air supply or air return. Installation of smoke detectors close to a ceiling fan, air supply, or air return can impede the operation of the smoke detector and can affect occupants in the office area, reception area and lounge. This deficient practice affects all occupants of the building. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Observation and interview on 8/26/14, revealed smoke detectors located within three feet of an air supply vent or return in patient rooms, offices, corridors and at fire doors throughout the facility. Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility is not assuring that a proper policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and residents. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

While review the outage policy on 8/26/14, the policy failed to list the phone numbers for the authorities having jurisdiction (AHJ): The State Fire Marshal's Office, Department of Inspections and Appeals, Insurance Company, and the Onawa Fire Department. Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility is not assuring that a proper 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 twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and residents. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

While review the outage policy on 8/26/14, the policy failed to list the phone numbers for the authorities having jurisdiction (AHJ): The State Fire Marshal's Office, Department of Inspections and Appeals, Insurance Company, and the Onawa Fire Department. Maintenance Staff A verified this observation.

Based on observation and interview, the facility is not providing a firewall with a two-hour rating between the patient area and the large mechanical room. This deficient practice would affect all occupant including staff, visitors and residents. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Observations and interview on 8/26/14, revealed the door from Mechanical Room 676 into the hospital did not close and latch properly when tested. According to facility layout, this is a two hour fire wall. Maintenance Staff A verified this observation.

Based on observation and interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly in their frames. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

1. Observation and interview on 8/26/14, revealed the Office door did not latch properly when tested.
2. Observation and interview on 8/26/14 revealed the Supply Room door was being propped open with a wedge.

Based on observation and interview, the facility failed to maintain the fire doors to close and resist the passage of smoke. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

1. Observation and interview on 8/26/14, reveled the fire door located by Lab 254 did not close when tested.
2. Observation and interview on 8/26/14, revealed the fire door located by Waiting Area 202 did not close and latch properly when tested.

Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility failed to test the emergency egress lighting as required. This deficient practice affects all occupants of the building. This facility has a capacity of 25 patients and a census of 7.

Findings include:

1. Observation, interview and record review on 8/26/14, revealed the absence of documentation to verify that 30 second monthly tests are being performed on the five emergency lights located throughout the building. The documentation showed that the 30 second test was performed in the following months for the last 12 months: January, April, May 2014 and September and October 2013.
2. Observation, interview and record review on 8/26/14, revealed the absence of documentation to verify that a 90 minute annual test has been performed within the last 12 months on one of five emergency lights (located in the Generator Hall).


Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain illuminated exit signs in proper working order. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Observations and interview on 8/26/14, revealed the exit signs in the following areas did not operate properly when tested: corridor outside PT, to stairway by elevator, by classroom, and at the top of the stairs on the east side of building going to the exterior exit. (All located at the clinic at 111 South 5th St., Mapleton).

Based on record review and staff interview, the facility is not conducting fire drills at varying times on each shift as required. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 residents and a census of 7.

Findings include:

Record review and staff interview on 8/26/14, revealed the facility failed to vary the times of the fire drills on each shift. On 1st shift, three of the four drills were performed within the same 30 minutes. On 2nd shift, all four drills were performed within the same 15 minutes. And on 3rd shift, all four drills were performed within a 30 minute time frame. Maintenance Staff A verified these observations.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed with direct airflow; not closer than three feet to air supply or air return. Installation of smoke detectors close to a ceiling fan, air supply, or air return can impede the operation of the smoke detector and can affect occupants in the office area, reception area and lounge. This deficient practice affects all occupants of the building. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Observation and interview on 8/26/14, revealed smoke detectors located within three feet of an air supply vent or return in patient rooms, offices, corridors and at fire doors throughout the facility. Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility is not assuring that a proper policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and residents. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

While review the outage policy on 8/26/14, the policy failed to list the phone numbers for the authorities having jurisdiction (AHJ): The State Fire Marshal's Office, Department of Inspections and Appeals, Insurance Company, and the Onawa Fire Department. Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility is not assuring that a proper 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 twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and residents. This facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

While review the outage policy on 8/26/14, the policy failed to list the phone numbers for the authorities having jurisdiction (AHJ): The State Fire Marshal's Office, Department of Inspections and Appeals, Insurance Company, and the Onawa Fire Department. Maintenance Staff A verified this observation.