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Based on observation and interview, it was determined the facility did not provide appropriate construction standards as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.1.6. The one-story Type III construction. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes are sealed with fire rated materials. This deficient practice affected one of four smoke zones. The facility had a capacity of 25 with a census of 5 patients at the time of the survey.

Findings include:

Observation and interview on 01/04/21 at 11:55 a.m., revealed the facility failed to maintain the ceiling in the Restroom next to the boiler Room. This room contained an approximately 1.5 foot by 1.5 foot hole in the monolithic ceiling. Maintenance Staff A verified this finding.

Based on observations and interviews, the facility failed to provide a one hour enclosure for the Kitchen in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2. The facility had a capacity of 25 and a census of 5 at the time of the survey.

Findings include:

Observation and interview on 01/04/21 at 10:04 a.m., revealed the door by the dishwashing area in the Kitchen did not latch properly when tested. The Maintenance Staff A 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 patients, staff, and visitors. The facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Record review and interview on 01/04/21 revealed the facility had a policy in place, however it failed to contain all the required information in it. The policy should contain all of the following:

Where a required fire alarm is out of service for more than 4 hours in a 24 hour period, the authority having jurisdiction (AHJ) shall be notified and the building shall be evacuation OR an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
a. Assign an impairment coordinator
b. Pre-planned or emergency
c. The person doing the fire watch shall be dedicated (with no other duties during the outage)
d. Occupants affected shall notified
e. Local fire department, Department of Inspection and Appeals and State Fire Marshal's office are to be notified at the beginning and end of the fire watch (include phone numbers in your policy)
f. The fire watch must be continuous and the person conducting the fire watch must be in each room every 30 minutes

Maintenance Staff A verified this observation.

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 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 staff and patients in the Decon Room. The facility had a capacity of 25 and a census of 5 at the time of the survey.

Findings include:

Observation and interview on 01/04/21 at approximately 12:15 p.m., revealed the facility failed to maintain the sprinkler system in the Decon Room. One of the sprinkler heads was coated with dust. The Maintenance Staff A 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 5 patients at the time of the survey.

Findings include:

Record review on 01/04/21 at 10:30 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. Determining the extent and expected duration of the impairment.
3. Submit recommendations to management.
4. When the system is out of service for more than 10 hours in a 24 hours 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 and implementation of an approved program to eliminate potential ignition
sources and limit the amount of fuel available to the fire
5. Notifying the fire department and the State Fire Marshal's Office (include phone numbers).
6. Notifying insurance carrier, the alarm company, property owner or designated representative and other AHJs (include all phone numbers).
7. Notifying the supervisors in the areas that are affected by the outage.
8. 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.
9. All necessary tools and materials have been assembled on the impairment site.
10. Address the emergency impairments to include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
11. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
12. 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.
13. Supervisors have been advised that protection is restored.
14. The fire department has been advised that protection is restored.
15. The insurance carrier, alarm company, and Iowa DIA have been advised that protection is restored.
16. The impairment tag has been removed.

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

Based on record review and 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 patients, staff, visitors in one of four smoke zones. This facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

Record review and interview on 01/04/21 at 9:10 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. The facility has an attached clinic separated by fire doors installed in the two-hour firewalls separating the clinic from the hospital. There are two sets of fire doors in two different two-hour fire walls. These fire doors are required to be functionally tested annually by an individual with knowledge and understanding of the operating components of the type of door being subject to testing. Maintenance Staff A verified this finding during the survey.
Maintenance Staff A and the Administrator confirmed the documentation at the time of the survey.


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.

Based on observation and interview, the facility failed to maintain proper space heating appliances within the facility that have heating elements limited to 212 degrees Fahrenheit as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.8/19.7.8. The deficient practice would affect one of four smoke zones. This facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

Observation on 01/04/21 at 1:30 p.m., revealed one electric space heater was located in the Business Manager's Office.
Maintenance Staff A was unable to present specification sheets on the space heater that showed the heating elements would not exceed 212 degrees Fahrenheit.

Based on record review and interview, the facility failed to maintain and 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 and 6.4.4.2. 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 5 patients at the time of the survey.

Findings include:

Record review and interview on 01/04/21 at 9:35 a.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 Maintenance Staff A revealed that the facility was not aware of this requirement.

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 affects patients, visitors and staff in one of four smoke zones. The facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

1. Observation and interview on 01/04/21 at 12:16 p.m., revealed a plastic power strip under the desk in the Business Manager's Office.

2. Observation and interview on 01/04/21 at 11:50 a.m., revealed two plastic power strips in the Cardiac Therapy Room. These strips were piggy backed into each other.

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