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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) [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 11 residents at the time of the survey.

Findings include:

Record review and interview on 9/27/21 at 10:06 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; and

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 observation and interview, the facility failed to maintain the fire alarm system within the building in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code and Signaling Code, 2010 edition. This deficient practice could affect all occupants within the facility. The facility had a capacity of 25 and a census of 11 residents at the time of the survey.

Findings include:

Observation on 9/27/21 at 11:07 a.m., revealed two smoke detectors that were not securely fastened to the ceiling and were hanging by its wires within the OB Storage Closet. Interview of the Maintenance Supervisor revealed the facility is undergoing smoke detection and fire alarm upgrades and that the fire alarm contractor had left a couple of smoke heads unattached to the ceiling and will be eventually reattaching them.

The Maintenance Director verified this finding at the time of the survey.

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 11 residents at the time of the survey.

Findings include:

Record review and interview on 9/27/21 at 10:15 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Interim Life Safety Management Policy, revealed the intervals at which security personnel were directed to perform fire watches, or make rounds in the facility to check every area for fire, were stated to be every hour. Approved fire watches require every space in the facility to be checked for fire at least every 30 minutes. The policy also did not state that the fire watch designee is to be dedicated to that sole duty, and that the fire watch is to be continuous until the system is restored.

The Maintenance Director verified this 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 Patient Lobby Hall. The facility had a capacity of 25 and a census of 11 at the time of the survey.

Findings include:

Observation on 09/27/2021 at 11:39 a.m., revealed the facility failed to maintain the sprinkler system in the Patient Lobby Hall that leads to the Med Surge Hall. The sprinkler head located next to the ceiling vent within this hall contained lint and dust throughout.

The Maintenance Director verified this finding at the time of the survey.

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 11 residents at the time of the survey.

Findings include:

Record review on 9/27/2021 at 9:51 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 Director verified the documentation at the time of the survey process.

Based on observation, record review 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 could affect residents, staff, and visitors who may be in the Med Surge Hall. This facility had a capacity of 25 and a census of 11 residents at the time of the survey.

Findings include:

Observation on 9/27/21, at 11:39 a.m., revealed a rubber door wedge lying on the ground next to the Wash Room entrance door located by Room 150. This Wash Room door was installed with a self closing device.

The Maintenance Director verified this finding at the time of the survey.

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 11 residents at the time of the survey.

Findings include:

Record review and interview on 9/27/2021, at 10:31 a.m., revealed the facility was unable to locate/provide a complete fire safety evacuation plan. The facility provided a policy that described what to do in the event of a fire alarm, but did not have a policy in place regarding the following plans and procedures: use of alarms, response to alarms, isolation of fire, evacuation of immediate area, extinguishment of fire, use of hood extinguishment, transmission of alarms to local department, emergency phone call to department (who), preparation of floors and building for evacuation, evacuation of smoke compartment, use of different types of extinguishers, safe area identified (evacuation area), and proper use of K rated extinguisher.

The Maintenance Director verified this finding at the time of the survey.

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 respectively, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. 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. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 11 residents at the time of the survey.

Findings include:

Record review on 9/27/2021 at 9:31 a.m., revealed the weekly generator inspection checklist did not contain belts/hoses as required.

The Maintenance Director confirmed this finding during the survey.