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UNITYPOINT HEALTH - MARSHALLTOWN
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of seven smoke compartments in the building. This could affect four staff, residents and visitors in the facility. The facility has a capacity of 16 and a census of 13.
Findings include:
Observation and interview on 7/20/2022 at 11:40 a.m., revealed the facility failed to separate the Wound Care Storage Room from other compartments. This room contained combustible storage, was over one hundred square feet and the door failed to contain a self closing device.
The Maintenance Director verified this observation at the time of the survey process.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2011 edition of NFPA 25, by ensuring that sprinkler heads have an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This could effect 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 occupants in this facility with a capacity of 16 and a census of 13.
Findings include:
Observation and interview on 7/20/2022 at 11:10 a.m., revealed the facility failed to maintain the sprinkler system in the Lab Reception Commons Area. This Commons Area contained one sprinkler head without an escution ring.
The Maintenance Director verified this observation at the time of the survey process.
Fire Drills
Tag No.: K0712
Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 16 and a census of 13.
Findings include:
Review of the facility's fire drill records on 07/20/2022 at 10:10 a.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2022. The facility failed to provide documentation of any fire drills being conducted on the first, second or third shift, second quarter of 2022.
The Maintenance Director verified this through record review at the time of the survey process.