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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 a self-closing device on the Kitchen Pantry Door. This deficient practice affects one smoke zone and could affect kitchen staff within the affected zone. The facility had a capacity of 25 residents and a census of 4.

Findings include:

Observation and interview on 8/15/19, at 12:40 p.m., revealed the Kitchen Pantry 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 dried goods.

Maintenance Staff A and B 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 4 residents at the time of the survey.

Findings include:

Record review and interview on 8/15/19, at 11:20 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 local fire department, Iowa Department of Inspections and Appeals (DIA; Authority Having Jurisdiction) and the State Fire Marshal's Office at the beginning or conclusion of the fire watch or include any procedures for how to conduct a fire watch.

Maintenance Staff A and B verified the documentation at the time of the survey process.

Based on record review, observation, and interview the facility failed to 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, 5.2.1.1.2, 5.4.1.6 and 14.2, by failing to ensure sprinkler heads were clean and free of foreign debris, not providing a sprinkler wrench kept in the sprinkler cabinet or documentation of remediation of deficiencies identified by the sprinkler system contractor. This deficient practice could affect all smoke compartments and occupants of the facility. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Record review, observation and interview on 8/15/19, between 10:00 a.m. and 1:55 p.m., revealed the following deficiencies:

1) The facility was unable to provide documentation of an internal obstruction assessment of piping and branch line conditions. The last five year internal inspection was verified and conducted by Continental Sprinkler Company in September 2010.

2) The sprinkler cabinet located in the Basement Sprinkler Riser Room did not contain any sprinkler wrenches. The sprinkler cabinet contained a stock of six spare sprinkler heads as required, but a sprinkler wrench was not found in the cabinet or in the vicinity of the sprinkler riser.

3) The sprinkler head located on the ceiling (near the vent) in Room 309 contained a large amount of foreign debris.

4) The sprinkler head located on the ceiling (near the vent) in Room 307 contained a large amount of foreign debris.

5) The sprinkler head located on the ceiling (near the vent) in the Lab Office Room contained a large amount of foreign debris.

Maintenance Staff A and B verified these findings at the time of 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 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 4 residents at the time of the survey.

Findings include:

Record review and interview on 8/15/19, at 11:30 a.m. of the fire watch procedures for a sprinkler system outage in the facility's Fire Watch - Sprinkler System policy, revealed the policy did not instruct facility personnel to contact the local fire department, Iowa Department of Inspections and Appeals (DIA; Authority Having Jurisdiction), the State Fire Marshal's Office or the insurance carrier at the beginning or conclusion of the fire watch or include any procedures for how to conduct a fire watch.

Maintenance Staff A and B verified the documentation at the time of the survey process.

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 three of fifteen smoke compartments and could affect all residents, staff, and visitors in the affected zones. This facility has a capacity of 25 with a census of 4.

Findings include:

Observation and interview on 8/15/19, between 12:50 p.m. and 2:15 p.m. revealed the following deficiencies:

1) The Generator Room Door contained a kick down device on the lower part of the door. This kick down device was in use and the door was propped open during the survey.

2) The two General Clinic Doors contained magnetic friction hold open devices that were not connected to the fire alarm system. This room was over 50 square feet in size and contained combustibles.

3) The door to Room 122 (located in the Old ER Hall) failed to close and latch when tested. The door closed within the door frame, but failed to catch the striker plate.

Maintenance Staff A and B confirmed these observations during the survey process.

Based on observation and interview, the facility failed to ensure the building's electrical system, wiring, and equipment are in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.1.2 and NFPA 70, National Electrical Code, 2011 edition, 110.26, by not providing or maintaining access and working space about electrical equipment. This deficient practice affects two staff in one of fifteen smoke zones. This facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Observation and interview on 8/15/19, at 11:40 a.m., revealed the facility failed to maintain clearance around the electrical panel in the Boiler Room. This electrical panel had a large plastic trash can stored in front of it.

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

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 4 residents at the time of the survey.

Findings include:

Record review and interview on 8/15/19, at 9:30 a.m., revealed the facility could not provide 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 and B 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 4 residents at the time of the survey.

Findings include:

Record review and interview on 8/15/19, at 9:45 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 and B confirmed this finding at the time of the survey.

Based on observation, record review and interview, the facility failed to maintain complete documentation of the inspections, exercising, and operation of the emergency generator power supply and to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 5.6.5.6, 8.3.4 and 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards, providing an emergency shut off for the generator and conduct an annual load bank test on the diesel generator. The facility also failed to exercise the components of the essential electrical system (EES) circuitry as required by NFPA Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. These deficient practices affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Observation, record review and interview on 8/15/19, between 10:08 a.m. and 10:50 a.m., revealed the following deficiencies:

1) The facility could not provide documentation of an annual fuel quality test to ASTM standards for the generator diesel fuel.

2) The facility was unable to provide evidence of an annual load bank test in lieu of the 30% monthly test showing the appropriate increments, as required.

3) 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 Maintenance Staff A and B revealed the facility was unaware of this requirement.

4) The facility's emergency generator was not equipped with a remote manual stop mechanism (emergency shut-off) external to the generator room.

Maintenance Staff A and B confirmed these findings and record review during the survey.

Based on observations 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 within the facility. These deficient practices affect staff in one of fifteen smoke compartments. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Observations and interview on 8/15/19, between 11:55 a.m. and 12:20 p.m. revealed the following deficiencies:

1) There was a surge protector providing power to a coffee maker and a small refrigerator in the Basement Business Office.

2) There was a surge protector providing power to a small refrigerator in the Basement IT Office.

Maintenance Staff A and B verified these observations at the time of the survey process.