HospitalInspections.org

Based on observations and staff interview, this facility is not providing a firewall with a two-hour fire rating between the nursing home and the assisted living facility. This deficient practice affects all occupants including staff, visitors and residents. The facility has a capacity of 17 with a census of 3 residents.

Findings include:

Observations and staff interview on 6/17/15, between 10:30 a.m. and 1:30 p.m., revealed the following deficiencies:

1. There was an open pipe, (approximately 1 inch), that was not properly sealed extending through the 2 hour wall by Surgery.
2. There was a hole, (approximately 3 inches), extending through the 2 hour wall separating the Hospital from the Medical Clinic.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. The deficient practice affects all occupants of the building. The facility has a capacity of 17 with a census of 3 patients.

Findings include:

Record review and staff interview on 6/17/15 at 11:04 a.m., revealed no available documentation of the last annual 90 minute testing of the emergency lighting system. Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to an air supply or return vent can impede the operation of the smoke detector. The facility has a capacity of 17 with a census of 3 residents.

Findings include:

Observation and staff interview on 6/17/15 at 12:04 p.m., revealed a smoke detector installed within three feet of an air supply or return vent in Room PR153. Maintenance Staff A verified observations during the survey process.

Based on observations, record review and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 17 with a census of 3 patients.

Observations, record review and staff interview on 6/17/15, between 10:30 a.m. and 1:30 p.m., revealed the following deficiencies:

1. There was no available documentation of a sprinkler system inspection report for
the 4th Quarter of 2014.
2. There was no available documentation of weekly 10 minute testing of the electric fire pump for the sprinkler system. The facility is testing the pump on a monthly basis.
3. There was tape observed covering 4 sprinkler heads in the Maintenance Office.

Maintenance Staff A verified record review and observations during the survey process.

Based on record review and staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. This deficient practice affects occupants in one of six zones. The facility has a capacity of 17 with a census of 3 patients.

Findings include:

Record review and staff interview on 6/17/15 at 12:42 p.m., revealed the facility was not conducting monthly Kitchen hood and duct extinguishment system inspections which includes all components of the system. Interview with facility staff indicated that monthly inspections include a cleanliness inspection only.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 17 with a census of 3 patients.

Findings include:

Record review and staff interview on 6/17/15 at 11:00 a.m., revealed no available documentation of weekly inspections of the generator. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to ensure the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 17 with a census of 3 residents.

Findings include:

Record review and staff interview on 6/17/15 at 11:23 a.m., revealed the outage policy for the sprinkler system did not contain notification of the Iowa Department of Inspections and Appeals as joint authority having jurisdiction. The policy also did not list the current number for the Iowa State Fire Marshal. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to ensure the policy 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 twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 17 with a census of 3 residents.

Findings include:

Record review and staff interview on 6/17/15 at 11:23 a.m., revealed the outage policy for the fire alarm system did not contain notification of the Iowa Department of Inspections and Appeals as joint authority having jurisdiction. The policy also did not list the current number for the Iowa State Fire Marshal. Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, this facility is not providing a firewall with a two-hour fire rating between the nursing home and the assisted living facility. This deficient practice affects all occupants including staff, visitors and residents. The facility has a capacity of 17 with a census of 3 residents.

Findings include:

Observations and staff interview on 6/17/15, between 10:30 a.m. and 1:30 p.m., revealed the following deficiencies:

1. There was an open pipe, (approximately 1 inch), that was not properly sealed extending through the 2 hour wall by Surgery.
2. There was a hole, (approximately 3 inches), extending through the 2 hour wall separating the Hospital from the Medical Clinic.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. The deficient practice affects all occupants of the building. The facility has a capacity of 17 with a census of 3 patients.

Findings include:

Record review and staff interview on 6/17/15 at 11:04 a.m., revealed no available documentation of the last annual 90 minute testing of the emergency lighting system. Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to an air supply or return vent can impede the operation of the smoke detector. The facility has a capacity of 17 with a census of 3 residents.

Findings include:

Observation and staff interview on 6/17/15 at 12:04 p.m., revealed a smoke detector installed within three feet of an air supply or return vent in Room PR153. Maintenance Staff A verified observations during the survey process.

Based on observations, record review and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 17 with a census of 3 patients.

Observations, record review and staff interview on 6/17/15, between 10:30 a.m. and 1:30 p.m., revealed the following deficiencies:

1. There was no available documentation of a sprinkler system inspection report for
the 4th Quarter of 2014.
2. There was no available documentation of weekly 10 minute testing of the electric fire pump for the sprinkler system. The facility is testing the pump on a monthly basis.
3. There was tape observed covering 4 sprinkler heads in the Maintenance Office.

Maintenance Staff A verified record review and observations during the survey process.

Based on record review and staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. This deficient practice affects occupants in one of six zones. The facility has a capacity of 17 with a census of 3 patients.

Findings include:

Record review and staff interview on 6/17/15 at 12:42 p.m., revealed the facility was not conducting monthly Kitchen hood and duct extinguishment system inspections which includes all components of the system. Interview with facility staff indicated that monthly inspections include a cleanliness inspection only.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 17 with a census of 3 patients.

Findings include:

Record review and staff interview on 6/17/15 at 11:00 a.m., revealed no available documentation of weekly inspections of the generator. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to ensure the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 17 with a census of 3 residents.

Findings include:

Record review and staff interview on 6/17/15 at 11:23 a.m., revealed the outage policy for the sprinkler system did not contain notification of the Iowa Department of Inspections and Appeals as joint authority having jurisdiction. The policy also did not list the current number for the Iowa State Fire Marshal. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to ensure the policy 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 twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 17 with a census of 3 residents.

Findings include:

Record review and staff interview on 6/17/15 at 11:23 a.m., revealed the outage policy for the fire alarm system did not contain notification of the Iowa Department of Inspections and Appeals as joint authority having jurisdiction. The policy also did not list the current number for the Iowa State Fire Marshal. Maintenance Staff A verified record review during the survey process.