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Based on record review and staff interview, the facility's Emergency Preparedness Plan failed to identify primary and secondary means of communication to be used during an emergency situation as required by 42 CFR 482.15(c)(3). The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Record review and staff interview on 8/30/18 at 12:06 p.m., revealed the facility's Emergency Preparedness Plan did not contain identification of primary and secondary means of communication to be used during an emergency situation as required. Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, the facility failed to maintain all 2 hour rated walls with doors at least 1-1/2 hour fire rated in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observations and staff interview on 8/29/18, between 9:30 a.m. and 3:30 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 1 inch), around a conduit extending through the 2 hour rated wall by the Emergency Department Entrance.
2. There was a hole, (approximately 1/4 inch), extending through the 2 hour rated wall by the Emergency Department Entrance.
3. There was a penetration, (approximately 1-1/2 foot by 2 inches), around communications lines, extending through the 2 hour rated wall to Radiology from the Emergency Department.
4. There was a penetration, (approximately 1 inch), around communications lines, extending through the 2 hour wall above the Surgery Hallway East Fire Doors.
5. There was an open pipe, (approximately 1-1/2 inch), extending through the 2 hour wall above the Surgery Hallway East Fire Doors.
6. There was a penetration, (approximately 1/4 inch), around a copper pipe, extending through the 2 hour rated wall by Elevator #3 on the First Floor.
7. There was a penetration, (approximately 1/2 inch), around communications lines, extending through the 2 hour wall by Room 236.
8. There was a penetration, (approximately 1/4 inch), around an electrical junction box, extending through the 2 hour wall by Room 236.
9. There was a penetration, (approximately 1/2 inch), around a pipe extending through the 2 hour wall by Room 236.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to test and maintain the emergency lighting system in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 7.9 and 19.2.9.1. A monthly test of the system for 30 seconds shall be conducted. A yearly test of the system for 90 minutes shall be conducted. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observation and staff interview on 8/29/18 at 3:16 p.m., revealed no available documentation of testing for the emergency lighting system for July, 2018. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain all stairwell walls at a minimum of one hour fire rated construction in accordance with 2012 Life Safety Code, 19.3.1.1 through 19.3.1.6. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observation and staff interview on 8/29/18 at 12:56 p.m., revealed a penetration, (approximately 1/2 inch), around a pipe extending through the Medical/Surgical South Stairwell Wall above the fire doors. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observation and staff interview on 8/29/18 at 11:16 a.m., revealed an excess buildup of grease and dirt on the filters of the Kitchen Hood and Duct Extinguishment System. Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. The primary power supply for the fire alarm system shall be mechanically protected. The location of the primary power supply for the fire alarm system shall be labeled at the main fire alarm control panel. Smoke detectors shall not be installed close to air supply or return ventilation ducts. The deficient practice affects all occupants of the building. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observations and staff interview on 8/29/18, between 9:30 a.m. and 3:30 p.m., revealed the following deficiencies:

1. The location of the power supply for the fire alarm system was not labeled at the main fire alarm
control panel.
2. The circuit breaker supplying power to the fire alarm system was not mechanically protected.
3. There were two smoke detectors installed near air supply or return vents by the Radiology West Fire
Doors.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide automatic fire alarm system occupant notification in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.4.3.1 and 9.6.3.5. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observation and staff interview on 8/29/18 at 10:02 a.m., revealed an enclosed courtyard near the Main Entrance of the facility. The occupants inside the courtyard would be required to re-enter the building to exit the space in the event of an emergency. Interview of Maintenance Staff revealed the courtyard did not contain fire alarm system components capable of providing audible or visual signals to notify courtyard occupants of activation of the fire alarm system.

Based on record review and staff interview, the facility failed to inspect and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. All initiating and notification devices shall be listed separately on an inspection report. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Record review and staff interview on 8/30/18 at 10:44 a.m., revealed all initiating and notification devices were not separately listed on the last three fire alarm inspection reports dated: 3/10/17, 9/22/17 and 3/4/18. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Record review and staff interview on 8/30/18 at 10:16 a.m., revealed the following deficiencies:

1. The facility's fire alarm outage policy did not contain notification of the State Fire Marshal, the Iowa Department of Inspections and Appeals and Newton Fire Department as Authorities Having Jurisdiction. The policy also did not contain phone numbers for each AHJ.
2. The facility's fire alarm outage policy did not contain all of the following required language:
"When the fire alarm system is out of service for more than 4 hours in a 24 hour period, the Impairment
Coordinator shall arrange for one of the following:
a) Evacuation of the building or portion of the building affected by the outage.
b) An approved fire watch. The policy should state that the fire watch is continuous and that all portions of
the facility will be checked at least once every 30 minutes.

Maintenance Staff verified record review during the survey process.

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Record review, observations and staff interview on 8/29/18, between 9:30 a.m. and 3:30 p.m., revealed the following deficiencies:

1. There was no available documentation of a 5 year sprinkler system inspection.
2. There was a dirty sprinkler head in the Emergency Department by Room 8.

Maintenance Staff verified record review and observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, NFPA 25, 15.5.2, 2011 Edition. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Record review and staff interview on 8/30/18 at 10:16 a.m., revealed the facility's sprinkler system outage policy did not contain all of the required information as follows:

1. The policy did not state the extent and expected duration of the impairment have been determined.
2. The policy did not state that the areas or buildings involved have been inspected and increased risks determined.
3. The policy did not state that recommendations have been submitted to management or the property owner.
4. The policy did not include notification and phone number for the Newton Fire Department.
5. The policy did not contain notification and phone numbers for the following: The alarm company. Iowa State Fire Marshal. Iowa Department of Inspections and Appeals.
6. The policy did not state that all necessary tools and materials have been assembled on the impairment site.
7. The policy did not address all of the following conditions: System leakage. Interruption of water supply. Ruptured piping. Equipment failure.
8. The policy did not contain all of the following language:
" When the sprinkler system is out of service for more than 10 hours in a 24 hour period, the
Impairment Coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the outage.
(b) An approved fire watch.
(c) Establishment of a temporary water supply.
(d) Establishment and implementation of an approved program to eliminate potential ignition sources
and limit the amount of fuel available to the fire."

Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility failed to maintain corridor walls as required. Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour. When certain provisions are met, such as smoke detection interconnected to the fire alarm, certain rooms may be open to the corridor. 2012 NFPA 101 existing edition,19.3.6.2 and 19;.3.6.2.7. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

There was a penetration, (approximately 3/16 inch), around an open pipe, extending through the corridor wall above the South Entry to Plant Operations. Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observations and staff interview on 8/29/18, between 9:30 a.m. and 3:30 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around a conduit extending through the smoke barrier wall at the Radiology West Fire Doors.
2. There was a penetration, (approximately 1/4 inch), around a ventilation duct, extending through the smoke barrier wall by Outpatient Surgery/Recovery.
3. There were two penetrations, (both approximately 1/4 inch), around cement supports, extending though the smoke barrier wall at the ICU Smoke Barrier Doors.
4. There was a penetration, (approximately 1/2 inch), around an insulated pipe and communications lines, extending through the smoke barrier wall in the Medical/Surgical Unit by Room 212.

Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association, NFPA 70, 2010 edition, by ensuring that all circuit breakers are identified. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observations and staff interview on 8/29/18, at 10:14 a.m., revealed that circuit breakers were not identified in the following electrical panels: LG1. CGA - SEC 1. CGA - SEC 2. LGA. NGA - SEC 2. CGB. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide emergency plans and procedures as required by National Fire Protection Association, NFPA 101, 2012 Edition, 19.7.2.2. The deficient practice affects all occupants of the building. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Record review and staff interview on 5/9/18 at 11:05 a.m., revealed the facility's fire emergency plan and procedure did not contain activation of the Kitchen Hood and Duct System. Maintenance Staff verified record review during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills and maintain proper documentation of fire drills under varied conditions at different times of the day for one of four quarters reviewed in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.7.1.4 through 19.7.1.7. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Record review and staff interview on 8/30/18 at 11:37 a.m., revealed the following deficiencies:

1. There was no available documentation of fire drills for the 1st and 2nd Shifts in the 1st Quarter of
2017.
2. There was no available documentation of a fire drill for the 3rd Shift in the 2nd Quarter of 2017.
3. There was no available documentation of a fire drill for the 2nd shift in the 3rd Quarter of 2017.

Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standard 99, 2012 edition. The remote annunciator was not installed at a work station that is occupied at all times. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observation and staff interview on 8/29/18 at 1:37 p.m., revealed the remote annunciator for the generator was installed in the Plant Operations Office. Interview with Maintenance Staff revealed the location is not staffed 24 hours a day.

Based on record review, observation and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. All required components must be checked during a weekly inspection. A remote stop station shall be provided as required. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Record review, observation and staff interview on 8/29/18 and 8/30/18, revealed the following deficiencies:

1. Observation on 8/29/18 at 1:37 p.m., revealed the remote manual stop station for the generator was installed in the same room as the generator set.
2. Record review on 8/30/18 at 9:57 a.m., revealed the following gaps in the weekly generator inspection log: 6/29/17 to 7/14/17. 12/14/17 to 12/28/17.
3. Record review on 8/30/18 at 9:57 a.m., revealed the weekly inspection log for the generator did not include checking the belts and hoses.

Maintenance Staff verified record review and observations during the survey process.

Based on observation and staff interview, the facility did not store compressed gas cylinders in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.6.2.3, by ensuring tanks were adequately secured to prevent them from accidental damage or dislocation. The facility has a capacity of 48 with a census of 5 patients.

Findings include:

Observation and staff interview on 8/29/18 at 1:48 p.m., revealed a compressed gas cylinder that was not properly secured in the Medical Gas Storage Room. Maintenance Staff verified observations during the survey process.