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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, 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 14 and a census of 1 patient at the time the survey.

Findings include:

Record review and interview on 09/20/21 at 8:20 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 Administrator verified this finding during the survey process.

Based on record review and interview, the facility did not properly document all required exercises conducted to test the emergency plan at least annually in accordance with the Code of Federal Regulations, 42 CFR §483.73(d)(2), by failing to provide documentation of participation in an exercise that may include a full-scale community-based or individual facility-based exercise. The facility also failed to perform a second exercise that could be a full-scale community-based or individual facility-based or a table top exercise. This deficient practice affects all occupants of the facility. The facility had a capacity of 14 and a census of one patient at the time of the survey.

Findings include:

Record review on 09/20/21 at 9:30 a.m., revealed the facility did not provide supporting documentation of any exercise conducted to simulate an actual emergency event or response of sufficient magnitude that required activation of the relevant emergency plans to meet the annual exercise requirements. Interview of the Administrator revealed facility staff had not participated in any exercises within the last 12 months due to COVID-19.

The Administrator verified these findings during the survey process.

Based on observation and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not 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 one light fixture in the Wound Center of the facility and could affect all occupants in the Wound Center. The facility has a capacity of 14 and a census of one.

Findings include:

Observation and interview on 09/20/21 at 12:50 p.m., revealed the battery backup emergency light located in the corridor by the Restroom in the Wound Center failed to illuminate when tested. The Maintenance Supervisor verified this observation at the time of 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 patients, staff, and visitors. The facility had a capacity of 14 and a census of one patient at the time of the survey.

Findings include:

Record review and interview on 09/20/21 at 11:22 a.m. revealed the facility had a policy in place, however it failed to contain all the required information in it. It should contain all of the following:

Where a required fire alarm is out of service for more than 4 hours in a 24 hour period, the authority having jurisdiction (AHJ) shall be notified and the building shall be evacuation OR an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
a. Assign an impairment coordinator
b. Pre-planned or emergency
c. The person doing the fire watch shall be dedicated (with no other duties during the outage)
d. Occupants affected shall notified
e. Local fire department, Department of Inspection and Appeals and State Fire Marshal's office are to be notified at the beginning and end of the fire watch (include phone numbers in your policy)
f. The fire watch must be continuous and the person conducting the fire watch must be in each room every 30 minutes

The facility produced a "Fire Policy" which contained information on the procedures to follow in case of a fire however, there was no outage policy available for review. The Administrator verified this observation.

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 14 and a census of one patient at the time of the survey.

Findings include:

Record review on 09/20/21 at 11:30 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. Determining the extent and expected duration of the impairment.
3. Submit recommendations to management.
4. When the system is out of service for more than 10 hours in a 24 hours period, the impairment coordinator shall arrange for one of the following:
A) evacuation of the building or portion of the building affected by the outage
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. Notifying the fire department.
6. Notifying insurance carrier, the alarm company, property owner or designated representative and other AHJ's.
7. Notifying the supervisors in the areas that are affected by the outage.
8. 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.
9. All necessary tools and materials have been assembled on the impairment site.
10. Address the emergency impairments to include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
11. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented.
12. 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.
13. Supervisors have been advised that protection is restored.
14. The fire department has been advised that protection is restored.
15. The insurance carrier, alarm company, and Iowa DIA have been advised that protection is restored.
16. The impairment tag has been removed.

This policy noted that it was last reviewed on 09/2021. The facility was not aware of these requirements

The Administrator verified the documentation at the time of the survey process.

Based on record review and interview, the facility failed to conduct fire drills under varied conditions/times 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 14 and a census of one patient at the time of survey.

Findings include:

Record review and interview on 09/20/21 at 11:00 a.m. of the facility's fire drill documentation, revealed the facility failed to vary the times for the p.m. shift fire drills. The fire drills for the p.m. shift for 2020/2021 were all within a 35 minute time frame (6:15 p.m.-6:50 p.m.). This facility operates on two shifts only. The Maintenance Director 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 all occupants of the building. This facility has a capacity of 14 and a census of one patient at the time of the survey.

Findings include:

1. Record review and interview on 09/20/21 at 10:36 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. The facility has two doors that go down to the Basement that 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. Interview of the Maintenance Director revealed he was unaware of the inspection requirement and verified this finding during 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, observations, 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 by not performing and properly documenting the monthly load tests and not having a fuel quality test performed annually. This deficient practice affects all smoke compartments of the building and all occupants. The facility had a capacity of 14 and a census of one patient at the time of the survey.

Findings include:

1. Record review and interview on 09/20/21 at 12:25 p.m., revealed the facility failed to maintain proper documentation of monthly load tests for the facility's emergency generator. A form has been sent to the Facility's Maintenance Director to show what items need to be documented for the monthly load tests. The Director of Maintenance acknowledged these findings during the survey process.

2. Record review and interview on 09/20/21 at 11:12 a.m., revealed the facility failed to have a fuel quality test annually approved by ASTM Standards. The Maintenance Director stated that he has not had this done.

The Facility's Director confirmed these findings during the survey.