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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 25 and a census of 0 residents at the time of the survey.

Findings include:

Record review and interview on 7/10/19, at 9:55 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 observation, record review and staff 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 normal lighting. This deficient practice affects all emergency light fixtures in the facility, including staff, residents and visitors. The facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Observation and record review on 7/10/19, between 11:45 a.m. and 12:45 p.m., revealed the following deficiencies:

1) The battery backup emergency light located in the Basement Elevator Shaft failed to illuminate when tested.

2) Record review revealed the last available documentation of the 90 minute annual emergency light testing was conducted on 4/10/18.

Maintenance Staff A and B verified this observation and record review at the time of the survey process.

Based on observation 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 failing to provide self-closing devices on hazardous rooms that exceed 50 square feet in size. This deficient practice affects one of four smoke zones and could affect residents, staff, and visitors within the affected zone. The facility had a capacity of 25 residents and a census of 0.

Findings include:

Observation and interview on 7/10/19, at 2:15 p.m., revealed the West Physical Therapy Storage Room exceeded 50 square feet in size and did not contain a self-closing device on the door.

Maintenance Staff A confirmed this observation at the time of the survey process.

Based on record review and staff interview, the facility failed to maintain the inspection and servicing schedule of the commercial cooking suppression system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.2.3 and NFPA Standard 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2. This deficient practice affects one of four smoke zones and could affect all residents, staff, and visitors in the Dining Room. The facility had a capacity of 25 and a census of 0 at the time of the survey.

Findings include:

Record review and interview on 7/10/19, at 11:20 a.m., of the facility's cooking operations documentation, revealed the facility failed to maintain the Kitchen hood suppression system. The facility failed to have the fire-extinguishing system and listed exhaust hood inspected and serviced at least every six months by properly trained and qualified persons as required. The facility provided documentation of inspections by Midwest Automatic Sprinkler Company dated 5/21/18 and 11/13/18. Interview of the Maintenance Staff A revealed they have the next service and inspection scheduled for 7/26/19.

Maintenance Staff A verified this record review during the survey process.

Based on record review and staff interview, the facility did not properly inspect or maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 edition, 14.6.2.4, 14.3.1, and 14.4.5., by ensuring the fire alarm system was inspected and tested on a semi-annual basis. This deficient practice would affect all residents, staff and visitors, including one out of four smoke zones. The facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Record review and interview on 7/10/19, at 11:10 a.m., of the facility's fire alarm inspection and testing documentation revealed the facility failed to maintain the fire alarm system. The facility failed to have the fire alarm system inspected and tested at least every six months by properly trained and qualified persons as required. The facility provided documentation of inspections by Midwest Automatic Sprinkler Company dated 5/21/18 and 11/13/18. Interview of the Maintenance Staff A revealed they have the next service and inspection scheduled for 7/26/19.

Maintenance Staff A verified this record review during the survey process.

Based on record review and staff 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 0 residents at the time of the survey.

Findings include:

Record review and interview on 7/10/19, at 10:20 a.m., of the fire watch procedures for a fire alarm system outage in the facility's Fire Watch - Fire Alarm policy revealed the policy did not instruct facility personnel to contact the Iowa Department of Inspections and Appeals (DIA; Authority Having Jurisdiction), or the local fire department at the beginning or conclusion of the fire watch and there were no phone numbers listed.

The Maintenance Supervisor verified the documentation at the time of the survey process.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1.2, by ensuring sprinkler heads were clean and free of foreign debris. This deficient practice of failing to provide prompt correction of deficiencies did not ensure proper operation and prompt repair of the system. This affected housekeeping staff including one out of four smoke zones in this facility with a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Observation and interview on 7/10/19, at 12:30 p.m., revealed the two sprinkler heads located above the dryer in the Laundry Room contained a large amount on lint and foreign debris.

This deficient practice was confirmed by Maintenance Staff B at the time of discovery.

Based on record review and staff interview, this facility did not assure that a 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 affected all occupants of the building, including residents, staff, and visitors. This facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

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

Maintenance Staff A confirmed the finding during the entrance conference.

Based on observation and staff 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., by ensuring unapproved door stops were not being used in the entire faciltiy. This deficient practice affected approximately 4 occupants in one of four smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Observation and interview on 7/10/19, at 1:15 p.m., revealed there was a door wedge located on the floor near the South Reception Entrance Door.

Maintenance Staff B confirmed this finding at the time of discovery.

Based on observation and staff interview, the facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls/ceilings in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects residents, staff, and visitors in one of four smoke zones. The facility has a capacity of 25 with a census of 0.

Findings include:

Observation and interview on 7/10/19, at 1:45 p.m., revealed there was a small gap (approximately 1/2 inch) around the 1/2 inch conduit piping extending through the lay-in ceiling located in the Surgery Center Mechanical Room.

Maintenance Staff B verified this observation at the time of the survey process.

Based on record review and staff 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 all residents, staff and visitors in all smoke compartments. This facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Record review and interview on 7/10/19, at 11:30 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.

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.

Maintenance Staff A confirmed the documentation 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 25 and a census of 0 residents at the time of the survey.

Findings include:

Record review and interview on 7/10/19, at 11:00 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)."

Maintenance Staff A confirmed this finding at the time of the survey.

Based on record review and staff interview, this facility did not maintain and test essential electrical system (EES) circuitry as required by National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. The deficient practice of not maintaining the generator and exercising the components of the essential electrical system (EES) main and feeder circuit breakers did not ensure proper operation and prompt repair affecting all occupants, including all staff, residents and visitors. This facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Record review and interview on 7/10/19, between 10:40 a.m. and 11:50 a.m., of the facilities generator inspection testing and maintenance records revealed the following:

1) The facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers. The main and feeder circuit breakers must be tested annually and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

2) The facility failed to document the time to transfer during the generator monthly load tests.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.

A.6.4.4.1.2.1 Main and feeder circuit breakers should be periodically
tested under simulated overload trip conditions to
ensure reliability.

6.4.4.2 Record Keeping. A written record of inspection, performance,
exercising period, and repairs shall be regularly
maintained and available for inspection by the authority having
jurisdiction.

Maintenance Staff A verified this record review at the time of the survey process.

Based on observation and staff interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 10.2.3.6 and Standard 70, National Electrical Code, 2011 edition, by failing to use general precautions with power strips and surge protectors within the facility. This deficient practice affects residents, staff and visitors in one of four smoke compartments. The facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Observation and interview on 7/10/19, at 1:00 p.m., revealed a surge protector was providing power to a refrigerator in the Public Health Office.

Maintenance Staff B verified this observation at the time of the survey process.