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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 area. The facility had a capacity of 25 and a census of 13 at the time of the survey.

Findings include:

Observation and interview on 08/03/2021 at approximately 12:16 p.m., revealed the facility failed to maintain the sprinkler system in the Kitchen area. Two sprinkler heads contained lint and dust throughout.

The Director of Facilities and the Maintenance Supervisor 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. 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 13 residents at the time of the survey.

Findings include:

Record review on 08/03/2021 at about 10:21 a.m. of the sprinkler outage policy revealed the facilities policy was incomplete and was missing many of its required components. A completed policy will address all 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.

6. When using a fire watch, the fire watch designee shall be Dedicated to the fire watch task. The fire watch shall also be Continuous while the sprinkler system is out of service.

The Director of Facilities and the Maintenance Supervisor verified this observation during the survey process.

Based on observation 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 individual in the EMS area, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 13 residents at the time of the survey.

Findings include:

Observation on 08/03/2021 at about 1:21 p.m., revealed two doors in the EMS area were observed to have door wedges holding the doors open during the time of this inspection.

The Director of Facilities and the Maintenance Supervisor verified this observation during the survey process.

Based on observation and interview, the facility is not assuring that two of two smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects 36 residents, staff, and visitors in three of three smoke zones. The facility has a capacity of 60 with a census of 41.

Findings include:

Observations and interview on 08/03/2021 at about 12:45 p.m., revealed the smoke barrier in the Medical Air Room had a 1/2" copper pipe that was cut and had not been capped off. This pipe would allow for the movement of smoke and fire.

The Director of Facilities and the Maintenance Supervisor verified this observation during 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 any occupants in the following rooms at risk of shock or loss of limb. The facility has a capacity of 25 and a census of 13.

Findings Include:

1. Observation and interview on 08/03/2021 at about 1:18 p.m., revealed the facility failed to maintain the electrical system in the Admin Hallway on the Second floor. This area contained outlet that had been used in the past for the drinking fountain. The outlet was with in twelve inches of a water source and did not have GFCI protection.

2. Observation and interview on 08/03/2021 at about 12:40 p.m., revealed the facility failed to maintain the electrical system in the Basement Floor Care Utility Area. This room contained an extension cord that was plugged in but was not in use at the time of this inspection.

3. Observation and interview on 08/03/2021 at about 12:41 p.m., revealed the facility failed to maintain the electrical system in the Boiler Entry Room. This room contained an open junction box that had 12 GA wires exposed.

The Director of Facilities and 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 25 and a census of 13 residents at the time of the survey.

Findings include:

Record review and interview on 08/03/2021 at 10:46 a.m. of the facility's evacuation plan, revealed several components of the Emergency Plans and Procedures (Fire Safety Plan) were missing. A complete plan would include the following:

Smoke evacuation Plan
Use of K extinguisher
Vertical Evacuation
Zone of origin evacuation
Use of alarms
Response to alarms
Isolation of fire
Evacuation of immediate area
Extinguishment of fire
Use of Hood extinguish system
Transmission of alarms to local Department
Emergency phone call to fire department (who)
Preparation of floors and building evacuation
Evacuation of smoke compartment
Use of different types of extinguishers
Safe area identified (evacuation area)
Emergency Plans & Procedures accessible to all staff on all shifts


The Director of Facilities and the Maintenance Supervisor verified this observation during the survey process.

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 13 residents at the time of the survey.

Findings include:

Record review and interview on 08/03/2021 at about 11:01 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. Maintenance records revealed the last maintenance of the main and feeder breakers was conducted in 2019.

The Director of Facilities and the Maintenance Supervisor verified this observation during the survey process.

Based on observation, interview and record review, the facility did not create an oxygen safety training program and maintain documentation of these proceedings in accordance with National Fire Protection Association (NFPA) Standard 99, 2012 edition, Health Care Facilities Code, 11.5.2.1.1, by ensuring personal concerned with the application and maintenance of medical gases and others who handle medical gases and cylinders that contain the medical gases are trained on the risks associated with handling these items. This deficient practice affected all personal who handle medical gases and cylinders in the facility. This facility had a capacity of 25 and a census of 13 residents at the time of the survey.


Findings include:

Observation and interview on 07/03/2021 at about 2:01 p.m., revealed a program to ensure personal concerned with the application and maintenance of medical gases and others who handle medical gases and cylinders that contain the medical gases are trained on the risks associated with handling these items. Interview of the Director of Facilities revealed a program had not been established for this required training.

The Director of Facilities and the Maintenance Supervisor verified this observation during the survey process.