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Based on observation and interview, the facility did not provide a firewall with a two-hour fire rating between the Hospital and the Dialysis Clinic as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.1.3.5/19.1.3.5 and 8.2.1.3. This compromises the fire-resistance rating of the wall and would allow the passage of fire,smoke and heated gases to the other side. This deficient practice could affect all occupants in the facility. This facility had a capacity of 25 and a census of 7.

Findings include:

Observation and interview on 2/3/2020, at 11:00 a.m., revealed the facility failed to maintain the two-hour firewall located between the Hospital and the Dialysis Clinic. These double doors failed to close and positively latch. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects two of twelve smoke compartments in the building. This could affect six staff, residents and visitor's in the Kitchen and Emergency Room. The facility has a capacity of 25 and a census of 7.

Findings include:

1. Observation and interview on 2/3/2020 at 11:15 a.m., revealed the facility failed to separate the Kitchen Dry Storage Room from other compartments. This room contained combustible storage, was approximately one hundred square feet and the door failed to contain a self closing device. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 2/3/2020 at 12:40 p.m., revealed the facility failed to separate Emergency Room Storage Room #J-13 from other compartments. This room contained combustible storage, was approximately eighty square feet and the door failed to contain a self closing device. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, affecting four staff, residents or visitor's in this room. The facility had a capacity of 25 and a census of 7.

Findings Include:

1. Observation and interview on 2/3/2020 at 10:42 a.m., revealed the facility failed to maintain the electrical system in the Marengo Family Clinic Electrical Room.. This room contained and open blank for breaker #54 of electrical panel #PL01. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 2/3/2020 at 11:30 a.m., revealed the facility failed to maintain the electrical system in the Main Boiler Room.. This room contained two open junction boxes along the ceiling. The Maintenance Director verified these observations at the time of the survey process.

3. Observation and interview on 2/3/2020 at 12:30 a.m., revealed the facility failed to maintain the electrical system in the Main Mechanical Room.. This room contained a conduit with two yellow electrical wires hanging out of it.. The Maintenance Director verified these observations at the time of the survey process.

4. Observation and interview on 2/3/2020 at 12:35 a.m., revealed the facility failed to maintain the electrical system in the Emergency Room Staff Restroom. This room contained an open junction box along the ceiling. The Maintenance Director verified this observation at the time of the survey process.

5. Observation and interview on 2/3/2020 at 1:00 p.m., revealed the facility failed to maintain the electrical system in the Emergency Room Registration Restroom. This room contained an open junction box along the ceiling. The Maintenance Director verified this observation at the time of the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 7.

Findings include:

Review of the facility's fire drill records on 2/3/2020 at 9:45 a.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2019. The facility failed to provide documentation of any fire drills being conducted on the second shift, fourth quarter of 2019. The Maintenance Director verified this through record review at the time of the survey process.

Based on interview and record review, the facility failed to maintain and document the emergency generator power supply as required. The deficient practice would affect all smoke compartments of the building and all of the residents, staff and visitors. The facility has a capacity of 25 and a census of 7.

Findings include:

1. Based on interview and record review on 2/3/2020 at 10:20 a.m., revealed that the facility failed to provide documentation of the oil, belts, battery and hoses during their weekly visual inspections for the facility's generator. The Maintenance Director verified this through interview and record review at the time of the survey process.

2. Based on interview and record review on 2/3/2020 at 10:35 a.m., revealed the facility could not provide documentation that the diesel generator is being tested to at least 30% of the name plate rating or conducting an annual load bank test. The Maintenance Director verified this through record review at the time of the survey process.