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Based on observation and interview, the provider failed to maintain proper separation between the hospital and one of two non-healthcare occupancies (attached apartments). Findings include:

1. Observation at 9:35 a.m. on 6/2/16 revealed the ninety minute fire rated door in the two hour fire separation wall between the hospital and attached apartments would not latch with the door closer. Interview with the facility director at the time of the observation confirmed the findings. He stated he was unaware the door would not latch and needed to monitor the doors in the fire separation walls more frequently.

The deficiency had the potential to affect the current patient (possible twenty-five patients) and staff.

Based on observation, interview, and record review, the provider failed to conduct the required flow switch and tamper valve testing of the automatic fire sprinkler system on a quarterly basis. Findings include:

1. Observation and record review at 10:35 on 6/2/16 revealed no documentation could be provided to indicate the quarterly flow switch testing and quarterly tamper valve testing had ever been completed since the system was installed. That requirement was told to the provider during the previous survey on 2/19/12. Interview with the facility director at the time of the observation and record review indicated he was not employed at the facility during the last survey and was unaware of the requirement.

This deficiency would affect all patients and staff present during a fire situation.

Based on observation, record review, and interview, the provider failed to test the emergency generator under load for thirty minutes as required on a monthly basis. Findings include:

1. Observation and document review at 11:30 a.m. on 6/2/16 revealed the diesel generator was started on a weekly basis, but no electrical load was transferred. Interview with the facility director at the time of the observation and record review indicated since his employment the generator had never been load tested to verify it would provide electricity to the facility in the event of a power outage. He indicated the generator did operate when a power outage occurred.

This deficiency would affect all patients and staff present during an emergency situation.