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Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR 483.475(b)(8) [LTC], by failing to incorporate policies and procedures in its emergency plan describing the facility's role under a waiver in accordance with Social Security Act, Section 1135, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 10 residents at the time of the survey.

Findings include:

Record review and interview on 12/10/2019 at 12:32 p.m., revealed the facility's emergency preparedness policies and procedures did not specifically address the facility's role in emergencies where the Health and Human Services Secretary declares a public health emergency. The emergency preparedness plan failed to demonstrate the facility's general awareness of the 1135 process, including the following:

1) Knowledge of how to request a waiver and who to contact (contact information) in the event an 1135 waiver needs to be requested;

2) The circumstances when an 1135 waiver might be granted based on the risk analysis;

3) How they would operate under and outline the responsibilities during the duration of the waiver period; and

4) How they would plan jointly on issues related to staffing, equipment, and supplies.

The Maintenance Supervisor and the Administrator verified this finding during 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 in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. 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 10 residents at the time of the survey.

Findings include:

Record review and interview on 12/10/2019 at 10:11 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Interim Life Safety Management Policy, revealed no contact numbers were provided for the Department of Inspection and Appeals to be contacted in the event of a fire alarm outage. The policy also did not state that the fire watch designee is dedicated & firewatch is continuous.

The Maintenance Supervisor verified the finding at the time of the survey.

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 Dining Room. The facility had a capacity of 25 and a census of 10 at the time of the survey.

Findings include:

1. Observation and interview on 12/10/2019 at 11:35 a.m., revealed the facility failed to maintain the sprinkler system in the West Hall. All sprinkler heads located next to ceiling vents contained lint and dust throughout. The Maintenance Supervisor verified this observation during the survey process.

2. Observation and interview on 12/10/2019 at 11:45 a.m., revealed the facility failed to maintain the sprinkler system in the West Hall above the Nurse's Station. All sprinkler heads located above this station contained lint and dust throughout. The Maintenance Supervisor verified this observation during the survey process.

3. Observation and interview on 12/10/2019 at 11:55 a.m., revealed the facility failed to maintain the sprinkler system in the Northwest Hall. All sprinkler heads located next to ceiling vents contained lint and dust throughout. 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 in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. 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 10 residents at the time of the survey.

Findings include:

Record review on 12/10/2019 at 10:05 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 record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. 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 had a capacity of 25 and a census of 10 residents at the time of survey.

Findings include:

Record review and interview on 12/10/2019 at 10:39 a.m. of the facility's fire drill documentation, revealed first, second, and third shift drills were conducted at approximately the same time of day. Four first shift drills were conducted between 11:00 a.m. and 1:45 a.m.: on 01/17/201 at 11:00 a.m., on 04/18/2019 at 11:00 a.m., on 7/15/2019 at 1:00 p.m., and 10/08/2019 at 1:45 p.m. Four second shift drills were conducted between 4:30 p.m. and 6:50 p.m.: on 02/21/2019 at 6:50 p.m., 05/16/2019 at 4:30 p.m., 8/10/2019 at 5:03 p.m., and 11/12/2019 at 6:30 p.m. Three third shift drills were conducted between 4:50 a.m. and 6:00 a.m.: on 03/19/2019 at 5:30 a.m., 9/13/2019 at 6:00 a.m., and 12/10/2018 at 4:50 a.m.

The Maintenance Supervisor verified the documentation during the survey process.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects eight residents, staff, visitors in one of seven smoke compartments. This facility had a capacity of 25 and a census of 10 residents at the time of the survey.

Findings include:

Record review on 12/10/2019 at 10:59 a.m., revealed the facility could not provide full documentation of annual inspection and testing of fire and/or smoke door assemblies within the facility. Interview of Maintenance Staff A revealed the facility conducts regular door inspections and documents them as completed, but that documentation did not contain verification of the 11 minimum items as required by code.

The Maintenance Supervisor confirmed the documentation at the time of the survey.



NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Based on record review and interview, the facility failed to maintain complete documentation of the inspections, exercising, and operation of the emergency generator power supply and to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4 and 8.3.8. The facility also failed to maintain and test essential electrical system (EES) circuitry as required by NFPA Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. These deficient practices affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 10 residents at the time of the survey.

Findings include:

1. Record review on 12/10/2019 at 10:25 a.m., revealed the facility failed to maintain proper documentation of monthly exercising under load for the facility's diesel generator. The facility did not document meter readings, the transfer switch being operated, date and run times, meter start & stop times recorded, and testing of the generator at the 30% nameplate rating. The Maintenance Supervisor verified this documentation at the time of the survey.

2. Record review on 12/10/2019 at 10:48 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. Interview of Maintenance Supervisor revealed the facility was completing the exercise, but was unable to maintain documentation.

The Maintenance Supervisor verified these findings at the time of the survey.

Based on observation and interview, the facility did not provide a proper storage of oxygen cylinders in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.3.2.3 and 11.6.5 by failing to separate oxygen from combustibles or materials and segregate and label empty cylinders from full cylinders, respectively. This deficient practice affects one of seven smoke compartments and any residents, staff, and visitors in the south Nurses Station area of the facility. The facility had a capacity of 25 with a census of 10 residents at the time of the survey.

Findings include:

Observation and interview on 01/10/2018 at 12:00 p.m., revealed the Oxygen Storage Room contained commingled oxygen cylinders that were not organized with any separation or provided labels designating empty or full.

The Maintenance Supervisor verified this observation during the survey.