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Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 10.5.5.3 by ensuring the fire alarm dedicated branch circuit(s) be mechanically protected. This deficient practice affects all occupants of the building, including clients, staff, and visitors. This facility has a capacity of 25 with a census of 5.

Findings include:

Observation on 11/07/2019 at 12:02 p.m., revealed the fire alarm breaker, located in electrical Panel ELLSLP1B in the First Floor Control Room, was not secured with a mechanical lock. Interview of the Director of Maintenance revealed he was not aware there was not one in place, and will contact Johnson Controls to have the breaker mechanically protected.

The Director of Maintenance verified this observation during 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 5 residents at the time of the survey.

Findings include:

Record review and interview on 11/07/2019 at 11:15 a.m. of the fire watch procedures for a fire alarm system outage revealed the facility did not have an adequate fire alarm outage policy in place. Interview of the Maintenance Director revealed he was aware of the 30 minute fire watch, but was unsure if there was an adequate policy in place.

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

Based on record review, observation, and interview, the facility failed to inspect and maintain the automatic sprinkler system within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 14.2, by not ensuring an internal inspection of the piping was conducted within the last five years, and 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 could affect all smoke compartments and occupants of the facility. The facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

1. Record review on 11/07/2019 at 10:10 a.m., of the facility's sprinkler system inspection reports, revealed the facility was unable to provide documentation of an internal obstruction assessment of piping and branch line conditions. Interview of the Director of Maintenance revealed he contacted the sprinkler contractor, who stated they had not conducted one in the previous five years. An inspection was scheduled at that time to be completed by Midwest Mechanical Service.

2. Observation and interview on 11/07/2019 between the times of 1:28 p.m. and 2:02 p.m., revealed the facility failed to maintain the sprinkler system at the following locations listed below. The sprinkler heads listed below contained lint and dust throughout. The Maintenance Supervisor verified these observations during the survey process.
A) 1: 28 p.m., the sprinkler head next to Room #278 next to EMT Sleeping Quarters on the 2nd Floor.
B) 1:46 p.m., the sprinkler head next to Atrium stair landing near the elevator on the 3rd Floor.
C) 1:51 p.m., the sprinkler head above Deck 3 located at the Nurses Station on the 3rd Floor.
D) 2:02 p.m., the sprinkler heads located in the Kitchen next to all ceiling fans.

The Maintenance Director confirmed these findings 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 5 residents at the time of the survey.

Findings include:

Record review on 11/07/2019 at 11:10 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.
(4) The insurance carrier has been notified and its phone number.
(5) The supervisors in the areas to be affected have been notified.
(6) A tag impairment system has been implemented.
(7) 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 and interview, the facility failed to install portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 2010 edition, 6.1.3.8.1 by ensuring the top of the fire extinguisher is not more than five feet above the floor. This deficient practice affects four fire extinguishers in four of five smoke compartments and could affect all residents, staff, and visitors. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 11/07/2019 at 12:33 p.m., revealed that the top of the fire extinguisher in the Elevator Mechanical Room on the 2nd Floor was mounted approximately 64 inches from the floor.

The Maintenance Director confirmed this observation during the survey.

Based on observations and interview, the facility is not ensuring resident room doors, office doors, and other ancillary area doors to the corridor resist the passage of smoke in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.6.3.1. This deficient practice would not prevent the spread of smoke, affecting one of four smoke compartments and could affect all residents, staff, and visitors in the affected zone which includes the Main Dining Room. This facility has a capacity of 25 with a census of 5.

Findings include:

Observation and interview on 11/07/2019 at 12:21 p.m., revealed the main entrance door to the Physical Therapy Room had an approximate 1/4 inch gap around the upper door frame while in the closed position.

The Maintenance Director confirmed this observation during the survey process.

Based on record review and interview, the facility failed to 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. The deficient practice affects four of seven smoke compartments and all residents, staff, and visitors. The facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Record review and interview on 11/07/2019 at 11:49 a.m., revealed the facility was unable to provide documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Interview of the Maintenance Director revealed the facility had completed this before his employment as Maintenance Director, and that he was unsure where or if there is any documentation that was kept of hospital-grade receptacle installation.

Based on record review and interview, the facility failed to maintain complete documentation of the inspections, tests, exercising, and operation of the emergency generator power supplies as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4 and could not provide documentation showing the emergency generator power supplies were exercised as required by NFPA Standard 110, 2010 edition, 8.4.2. These deficient practices affect all smoke compartments of the building and all occupants. The facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

1. Record review and interview on 11/07/2019 at 11:25 a.m., revealed the facility failed to maintain proper documentation of monthly load tests for the facility's emergency generators. The facility had not documented the generator amperages recorded for each leg, testing at 30% of the nameplate rating, and the transfer switch being operated for the facility's generator during any monthly 30-minute load test.

2. Record review and interview on 11/07/2019 at 11:25 a.m., revealed the facility failed to maintain proper documentation of the weekly inspection log. The facility did not include "Belts/Hoses" within the weekly checklist.

The Director of Maintenance acknowledged these findings during the survey process.