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Based on observations and staff interview, the facility failed to maintain all 2 hour rated walls with doors at least 1-1/2 hour fire rated in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Observations and staff interview on 4/2/21, between 8:30 a.m. and 1:00 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 3/16 inch), around an insulated pipe extending through the 2 hour rated wall by Room 103.
2. There was a penetration, (approximately 3/16 inch), around a pipe extending through the 2 hour rated wall by the Look Nook.
3. There was a penetration, (approximately 1/4 inch), around an insulated pipe extending through the 2 hour rated wall by the Look Nook.
4. There was a penetration, (approximately 1/4 inch), around a conduit extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. A placard shall be provided for the K-rated Extinguisher in the Kitchen. The deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Observation and staff interview on 4/2/21, between 8:30 a.m. and 1:00 p.m., revealed there was not a placard in place in the Kitchen which indicates that the Kitchen Hood and Duct Suppression system shall be activated before use of the K-rated extinguisher. Maintenance Staff verified observations and record review during the survey process.

Based on observations and staff interview, the facility failed to install and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. Smoke detectors shall not be located close to air supply or return ventilation ducts. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Observations and staff interview on 4/2/21, between 8:30 a.m. and 1:00 p.m., revealed the following deficiencies:

1. There was a smoke detector installed near (within 3 feet) a ventilation duct in the corridor outside the Business Office.
2. There was a smoke detector installed near (within 3 feet) a ventilation duct at the Emergency Department Nurses' Station.

Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Record review and staff interview on 4/2/21 at 12:26 p.m., revealed the outage policy for the fire alarm system did not contain all required language as follows:

1. The fire alarm outage policy did not contain all of the following language:
" When the fire alarm system is out of service for more than 4 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 outage.
b) An approved fire watch. The fire watch is continuous and all portions of the facility will be
checked at least once every 30 minutes."
2. The fire alarm outage policy did not contain notification of the Iowa Department of Inspections and Appeals as an authority having jurisdiction.

Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Observations and staff interview on 4/2/21, between 8:30 a.m. and 1:00 p.m., revealed the following deficiencies:

1. The valve on the post indicator valve for the sprinkler system was not properly secured in the open position. There was a padlock on the valve, however the padlock was not locked.
2. A sprinkler head in the Pharmacy was positioned incorrectly in the drop tile ceiling grid. The sprinkler pipe had been moved up, moving the head up too far into the ceiling tile grid. The spray pattern of the sprinkler head would potentially be affected in the event of activation.
3. A hydraulic nameplate was not provided at the sprinkler system riser as required.

Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. and NFPA 25, 15.5.2, 2011 Edition. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Record review and staff interview on 4/2/21 at 12:26 p.m., revealed the following deficiencies:

1. The policy did not name an Impairment Coordinator.
2. The policy did not contain language indicating that the extent and expected duration of the impairment have been determined.
3. The policy did not contain language indicating that the areas or buildings involved have been inspected and increased risks determined.
4. The policy did not contain language indicating that recommendations have been submitted to management or the property owner.
5. The policy did not contain language indicating that the supervisors in the affected areas have been notified.
6. The policy did not contain language indicating that all necessary tools have been assembled at the impairment site.
7. The policy did not address the following conditions: System leakage. Interruption of water supply. Ruptured piping. Equipment failure.
8. The policy did not contain notification of the Iowa Department of Inspections and Appeals as an authority having jurisdiction.
9. The policy did not include language on notification of authorities having jurisdiction at the beginning and conclusion of the impairment.
10. The outage policy for the sprinkler system did not contain all of the following required language:

"When the sprinkler 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 outage.
b) An approved fire watch.
c) Establishment of a temporary water supply.
d) Establishment an implementation of an approved program to eliminate potential ignition
sources and limit the amount of fuel available to the fire."

Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, the facility failed to maintain and test fire extinguishers as required by National Fire Protection Association, NFPA 10, 2010 edition. Fire extinguishers shall be properly mounted. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Observations and staff interview on 4/2/21, between 8:30 a.m. to 1:00 p.m., revealed the following deficiencies:

1. The fire extinguisher in the Ambulance Garage was not mounted as required by NFPA 10.
2. The fire extinguisher in the Generator Room was not mounted as required by NFPA 10.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide and maintain smoke barrier doors with a 20 minute fire rating in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.6. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Observation and staff interview on 4/2/21 at 8:30 a.m. to 1:00 p.m., revealed the following deficiencies:

1. There was an excess gap between the West Patient Wing Smoke Barrier Doors. The gap was large enough to easily see through the doors.
2. There was an excess gap between the Surgery/Dietary Smoke Barrier Doors. The gap was large enough to easily see through the doors.

Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide emergency plans and procedures as required by National Fire Protection Association, NFPA 101, 2012 Edition, 19.7.2.2. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Record review and staff interview on 4/2/21 at 12:22 p.m., revealed the following deficiencies:

1. The facility's fire emergency plan and procedures policy did not contain language on the use of the different types of fire extinguishers located through out the building.
2. The facility's fire emergency plan and procedures policy did not contain language on the use of the Kitchen Hood and Duct Extinguishment System.

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview the facility is not conducting and documenting annual testing of swinging fire door assemblies as required by National Fire Protection Association, NFPA 80, 2010 Edition. The facility has a capacity of 25 with a capacity of 2 patients.

Findings include:

Record review and staff interview on 4/2/21 at 12:43 p.m., revealed no available documentation of annual testing of swinging fire door assemblies as required. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. A monthly test under load for the generator set shall be properly documented. An annual fuel quality test shall be provided for a diesel powered generator set. The facility has a capacity of 25 with a census of 2 patients.

Findings include:

Record review and staff interview on 4/2/21 at 11:37 a.m., revealed the following deficiencies:

1. Documentation of monthly tests under load of the generator set did not contain amperage readings for all three legs of the system.
2. Documentation of monthly tests under load of the generator set did not contain start and stop meter readings during the testing.
3. There was no available documentation of an annual fuel quality test for the diesel powered generator.

Maintenance Staff verified record review during the survey process.