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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 483.73(b)(8), 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 11 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 7/25/19, at 10:25 a.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.

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

The Maintenance Supervisor verified this finding during the survey process.

Based on observations and interview, the facility is not providing exit doors that will not require more than 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 7.2.1.4.5., by ensuring delayed egress locking devices release upon activation. This deficient practice affected approximately 11 residents in the facility, including two out of five smoke zones. This facility had a capacity of 11 and a census of 3 residents at the time of the survey.

Findings include:

Observations and interview on 7/25/19, between 10:30 a.m. and 10:45 a.m., revealed the following deficiencies:

1) The fire rated double doors located near Radiology contained a 15 second delayed egress locking device. When tested this magnetic device (west door) would not lock into position, instead the magnet was release at all times. According to the facility layout, this was a required exit.

2) The smoke barrier double doors located near the Pharmacy contained a 15 second delayed egress locking device. When tested this magnetic device (west door) would not lock into position, instead the magnet was release at all times. According to the facility layout, this was a required exit.

The Maintenance Supervisor verified these findings during the survey process.

Based on record review and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of regular lighting. This deficient practice affects three light fixtures in the facility, including staff in three out of five smoke compartments. The facility had a capacity of 11 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 7/25/19, at 12:15 p.m., revealed the facility was unable to provide documentation of monthly or annual functional testing for any battery backup emergency light fixture throughout the building. Interview of the Maintenance Supervisor revealed the facility had conducted periodic testing of emergency lighting fixtures, but they had not maintained any records of the testing.

The Maintenance Supervisor verified this finding during the survey process.

Based on observations and interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2.1.3., by ensuring hazardous areas and storage rooms that exceeded 50 square feet in size contained a self-closing device to prevent the spread of smoke or fire. This deficient practice affects staff in two out of five smoke compartments. The facility had a capacity of 11 residents and a census of 3.

Findings include:

Observations and interview on 7/25/19, between 10:55 a.m. and 12:20 p.m., revealed the following deficiencies:

1) The Kitchen Pantry exceeded 50 square feet in size and did not contain a self-closing device on the door. This room contained storage of canned and dried goods.

2) The Electrical Panel Room located near the Nurses Station did not contain a self-closing device on the door.

The Maintenance Supervisor verified these findings 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 11 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 7/25/19, at 9:20 a.m., of the fire watch procedures for a fire alarm system outage in the facility revealed there was no policy in place in the event the fire alarm system was out of service for more than four hours in any 24-hour period. The policy failed to include the following criteria:

1) The policy did not instruct facility personnel to contact the local fire department, Iowa Department of Inspections and Appeals (DIA; Authority Having Jurisdiction) and the State Fire Marshal's Office at the beginning or conclusion of the fire watch and there were no phone numbers listed.

2) The policy lacked that the persons assigned to do the fire watch would be "dedicated".

3) The policy also lacked that the fire watch would be "continuous" and that all portions of the facility will be checked at least once every 30 minutes.

4) The policy did not include a timeframe on the outage of the system before implementation of the fire watch.

Record review of the facility layout showed this would affect all smoke zones.

The Maintenance Supervisor verified the record review at the time of the survey process.

Based on record review and staff interview, this facility did not assure that a 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 affected all occupants of the building, including residents, staff, and visitors. This facility had a capacity of 11 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 7/25/19, at 9:55 a.m., of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 10 hours in a 24-hour period. The policy failed to have the following information included in their policy as required by NFPA 25, 2011 Edition (Chapter 15):

15.2.1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter.
15.2.2 In the absence of a specific designee, the property owner or designated representative shall be considered the impairment coordinator.
15.2.3 Where the lease, written use agreement, or management contract specifically grants the authority for inspection, testing, and maintenance of the fire protection system(s) to the tenant, management firm, or managing individual, the tenant, management firm, or managing individual shall assign a person as impairment coordinator.
15.3 Tag Impairment System.
15.3.1* A tag shall be used to indicate that a system, or part thereof, has been removed from service.
15.3.2* The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service.
15.4 Impaired Equipment.
15.4.1 The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service.
15.4.2 The impaired equipment shall include, but shall not be limited to, the following:
(1) Sprinkler systems
(2) Standpipe systems
(3) Fire hose systems
(4) Underground fire service mains
(5) Fire pumps
(6) Water storage tanks
(7) Water spray fixed systems
(8) Foam-water systems
(9) Fire service control valves

15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.

15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that 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.
(4) Where a required fire protection 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 system out of service
(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
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

15.7 Restoring Systems to Service. 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 property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed.

The Maintenance Supervisor verified this finding during the survey process.

Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6 for one of four quarters reviewed. The documentation did not show the drills have been held as required. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 11 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 7/25/19, at 10:28 a.m. of the facility fire drill documentation conducted during 2019 revealed the following: No fire drills were conducted during the first quarter on all shifts in the hospital. Interview with the Maintenance Supervisor advised they only conducted one fire drill in the Medical Center in the first quarter.

The Maintenance Supervisor verified this finding during the survey process.

Based on record review and interview, this facility is not inspecting fire and/or smoke door assemblies in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2, by failing to inspect and test fire and/or smoke door assemblies annually. This deficient practice affects all residents, staff, and visitors in all smoke compartments. This facility had a capacity of 11 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 7/25/19, at 11:30 a.m., revealed the following deficiencies:

1) The facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. These fire and/or smoke doors are required to be functionally tested annually by an individual with knowledge and understanding of the operating components of the type of door being subject to testing.

2) The smoke barrier doors located in the Front Corridor failed to close properly during the fire alarm test. The magnetic device on the west door did release, however the door was dragging on the baseboard trim which prevented the west door from closing properly without assistance.

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.

5.2.5 Horizontally Sliding, Vertically Sliding, and Rolling Doors.

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

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.

5.2.7 Assembly shall be reset after a successful test.

5.2.8 Resetting of the release mechanism shall be done in accordance with manufacturer's instructions.

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

5.2.10 Tin-clad and kalamein doors shall be inspected for dry rot of the wood core.

5.2.11 Chains or cables employed shall be inspected for excessive wear and stretching."

The Maintenance Supervisor confirmed this finding at the time of the survey.

Based on record review and staff interview, the facility failed to conduct and document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2., by failing to test all hospital-grade receptacles in patient care areas at the time of install as required. The deficient practice affects all smoke compartments, including all residents, staff, and visitors. The facility had a capacity of 11 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 7/25/19, at 10:10 a.m., revealed the facility was unable to provide documentation of hospital-grade receptacle testing upon initial installation, replacement, or servicing of hospital-grade receptacles.

6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz)."

The Maintenance Supervisor confirmed this finding at the time of the survey.

Based on observation and interview, the facility failed to ensure the emergency generator for the building was properly equipped with a remote manual stop mechanism in accordance with National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 5.6.5.6. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 11 and a census of 3.

Findings include:

Observation and interview on 7/25/19, at 12:00 p.m., revealed the facility's emergency generator was not equipped with a remote manual stop mechanism (emergency shut-off) external to the weatherproof enclosure.

NFPA 110, Standard for Emergency and Standby Power Systems,
2010 edition, 5.6.5.6

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

A.5.6.5.6 For systems located outdoors, the manual shutdown
should be located external to the weatherproof enclosure
and should be appropriately identified.

The Maintenance Supervisor verified this observation at the time of the survey process.