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Based on record review and interview, the facility failed to document periodic testing of emergency lighting equipment in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.2.9.1 and 7.9.3. This deficient practice affects light fixtures in the entire building, along with all residents, staff, and visitors. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Record review on 9/16/20 at 11:51 a.m., revealed the facility was unable to provide documentation of annual 90 minute functional testing for any battery backup emergency light fixture throughout the building. Interview of the Maintenance Supervisor revealed the facility had conducted the required monthly 30 second testing and was aware of the annual 90 minute testing, but due to changes in maintenance staff, the annual 90 minute documentation was unable to be located.

The Maintenance Supervisor and the Administrator confirmed these findings during 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. This deficient practice affects one of five smoke zones and could affect staff, and visitors within the affected zone. The facility had a capacity of 25 residents and a census of 3.

Findings include:

Observation on 9/16/20 at 1:12 p.m., revealed the Pantry in the basement Kitchen exceeded 50 square feet in size and did not contain a self-closure device on the door. This room contained storage of canned as well as dry goods.

The Maintenance Director confirmed 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 residents, staff, and visitors. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 9/16/20 at 11:35 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) at the beginning or conclusion of the fire watch or include the contact phone number. The policy also did not include that the fire watch designee is to be dedicated and the firewatch is to be continuous. The policy should state that the fire watch is "continuous" and that all portions of the facility will be checked at least every 30 minutes.

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

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 along with a provided escutcheon ring 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 Basement. The facility had a capacity of 25 and a census of 3 at the time of the survey.

Findings include:

Observation on 09/16/2020 at approximately 1:33 p.m., revealed the facility failed to maintain the sprinkler system in the North Elevator Shaft Room. The sprinkler head within this room was missing its escutcheon ring.

The Maintenance Supervisor verified this observation during the survey process.

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 3 residents at the time of the survey.

Findings include:

Record review on 9/16/20 at 11:21 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.

Administrative Staff A, the Maintenance Director, and the Administrator verified the documentation at the time of the survey process.

Based on observation 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, 19.3.6.3. This deficient practice affected staff and visitors in one of five smoke zones, as the door would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Observation and interview on 9/16/20, at 12:52 p.m., revealed the door to Room #6 was observed to have a kick-down device installed on it. This door was installed with an automatic door closure.

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

Based on observation and interview, the facility failed to install the HVAC (heating, ventilating, and air conditioning) system in accordance with National Fire Protection Association (NFPA) Standard 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2012 edition, 4.3.12.1.1. This deficient practice could affect staff within the Basement Wash/Dryer Room. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Observation and interview on 9/16/2020, at 1:44 p.m., revealed the metal dryer ventilation was piped into a plastic lint trap, and was not being vented to the exterior of the building.

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

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for one 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 25 and a census of 3 residents at the time of survey.

Findings include:

Record review on 9/16/20 at 12:03 p.m. of the facility's fire drill documentation, revealed the facility failed to conduct or document a fire drill during the day shift (7 a.m.-7 p.m.) or evening shift (7 p.m.-7 a.m.) of the 4th quarter. Interview of Administrative Staff A revealed there was a staff change during this time, and that the documentation might have been relocated or lost during this change.

The Maintenance Director, Administrator, and Administrative Staff A confirmed this documentation at the time of the survey.

Based on record review and interview, the facility failed to test essential electrical system (EES) circuitry as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2, by not exercising of main and feeder circuit breakers. The deficient practice affects all of the smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Record review on 9/16/20 at 12:26 p.m., revealed the facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers. Interview of the Director of Maintenance revealed the facility was unaware of this requirement at the time of the survey.

The Director of Maintenance acknowledged this finding during the survey process.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, by failing to use general precautions with power strips and surge protectors and allowing the use of non-approved electrical devices or adapters within the facility. These deficient practices affect staff in two of five smoke compartments. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Observation and interview on 09/16/2020 between the times of 12:36 p.m. and 1:19 p.m., revealed the following surge protector deficiencies:
1. A surge protector providing power to a fridge and microwave within the Laboratory Room on the main floor.
2. A surge protector providing power to a fridge and microwave within the basement Maintenance Staff area.

The Maintenance Director verified these findings at the time of inspection.