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Based on record review and interview, the facility did not develop an emergency preparedness plan based on an all-hazards approach in accordance with the Code of Federal Regulations, 42 CFR §485.625(a)(1), by failing to include planning for infectious diseases within their emergency preparedness program. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review and interview on 04/15/2021 at 11:17 p.m., revealed the facility had not included emerging infectious diseases within its documented risk assessment. CMS determined it was critical for facilities to include planning for infectious diseases within their emergency preparedness program and to include consideration of preparedness and infection prevention within their all-hazards approach, which covers both natural and man-made disasters.

Administrative Staff verified these findings during the survey process.

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 8.

Findings include:

Observation on 04/15/2021 at 12:15 p.m., revealed the fire alarm breaker, located in electrical Panel JA, Circuit #10, in the Boiler Room, was not secured with a mechanical lock. The Director of Maintenance stated a contractor may have removed it to work on the electrical panel but then never reinstalled it.

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 8 residents at the time of the survey.

Findings include:

1. Record review and interview on 04/15/2021 at 10:05 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), or the insurance carrier at the beginning or conclusion of the fire watch or include any procedures for how to conduct a fire watch. The Maintenance Supervisor verified the documentation at the time of the survey process.

2. Record review and interview on 04/15/2021 at 10:05 a.m. of the fire watch procedures for fire alarm system outage indicated the policy did not include contact numbers for the agencies to be notified at the beginning and conclusion of a fire alarm outage lasting more than four hours in a twenty-four hour period. The Maintenance Supervisor verified the documentation at the time of the survey process.

3. Record review and interview on 04/15/2021 at 10:05 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Fire Alarm System Shutdown policy, revealed the policy did not state that the employee assigned to the fire watch shall be trained in fire prevention, as required and that the fire watch shall be 'continuous". The Maintenance Supervisor verified the documentation at the time of 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 8 residents at the time of the survey.

Findings include:

Record review on 04/15/2021 at 9:55 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 the following information:


1. 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.

2. 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.

3. Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

4. Outage policy includes Iowa DIA and phone number.

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.

6. Outage policy includes the designated fire watch designee is 'dedicated' & the fire watch is 'continuous'.

Administrative Staff member and 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, 6.1.3.4, by ensuring all portable, non-wheeled fire extinguishers are installed on a hanger, in a supplied or listed bracket, or in cabinets or wall recesses. This deficient practice affects one fire extinguisher in one of five smoke compartments and could affect staff in the IT Server Room. This facility had a capacity of 25 and a census of 8 patients at the time of the survey.

Findings include:

Observation on 04/15/2021 at 11:45 a.m., revealed the Class ABC fire extinguisher in the IT Server Room was not checked in 3/2021 during the monthly fire extinguisher checks.

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

Based on observation, record review and interview, the facility did not ensure 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, 18.3.6.3/19.3.6.3. This deficient practice affected staff in one of five smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 8 patients at the time of the survey.

Findings include:

Observation on 4/15/2021, at 11:35 a.m. revealed the door to the Kitchen Pantry was observed to have a large elastic strap extending from the wall to the inside door nob holding the door open.

The Director of Maintenance confirmed the findings at the times of discovery.

Based on observation and interview, the facility failed to provide heating devices that are designed and installed so that combustible material cannot be ignited by the device or its appurtenances according to National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.5.2.2, by using duct tape to seal vent piping sections for one of the clothing dryers in the Main Laundry Room. This deficient practice affect staff of the facility. The facility had a capacity of 25 and a census of eight at the time of the survey.

Findings include:

Observation and interview on 04/15/2021 at 11:31 a.m., revealed gray duct tape was used to secure and suspend sections of the dryer exhaust vent tubing on one of the electric dryers located in the Laundry Room.

The Maintenance Director confirmed this observation at the time of discovery.

Based on record review and interview, the facility failed to conduct/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 five of five smoke compartments and all patients, staff, and visitors. The facility had a capacity of 25 and a census of 8 patients at the time of the survey.

Findings include:

Record review and interview on 04/15/2021 at 10:51 a.m., revealed the facility was unable to provide documentation of non-hospital-grade receptacle testing or documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Interview of Maintenance Staff A revealed the facility had hospital-grade receptacles throughout the facility. No documentation of retention testing had been maintained after instillation. The Maintenance Director confirmed this finding at the time of the survey.


NFPA 99 Health Care Facilities Code, 2012 edition, 6.3.4.2 Record Keeping.

6.3.4.2.1.2 At a minimum, the record shall contain the date,
the rooms or areas tested, and an indication of which items
have met, or have failed to meet, the performance requirements
of this chapter.

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; failed to maintain and test 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. This deficient practice affect all smoke compartments of the building and all staff, visitors and patients. The facility had a patient capacity of 25 and a census of 8 patients at the time of the survey.

Findings include:

1. Record review and interview on 04/15/2021 at 10:33 a.m., revealed the facility could not provide any documentation for the generator weekly visual inspection during the third week of November 2020.

2. Record review and interview on 04/15/2021 at 10:33 a.m., revealed the facility could not provide any documentation for the generator weekly visual inspection during the first, second and third week of October 2020.

The Director of Maintenance acknowledged these findings 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. The facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation on 04/15/2021 at 12:02 p.m., revealed a surge protector providing power to a microwave oven in the OB Clean Utility Room. Maintenance Staff A verified this observation at the time of the survey process.