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Based on observation and staff interview during the course of the survey conducted on 05/09/2017 , it was determined the facility failed to properly maintain fire resistant coating on steel support beams in the accordance with NFPA 101, 19.1.6.1.

The following evidenced this: During the walk through of the facility with the Maintenance Engineer; two vertical support beams in the Shell Space Storage had part of their fire protective coating removed.
The deficiency has the potential to affect all occupants, who might include staff, residents and visitors.

This item was discussed during the survey and again during the exit conference.

Based on observation and staff interview during the course of the survey , it was determined the facility failed to maintain the 1st floor, 2- hour fire rating in accordance with NFPA 101, 19.2.2 and 7.1.

During the walk-through with the maintenance engineer; it was observed that the listed fire door assembly near the gift shop had been modified leaving exposed holes in the listed door frame.

This was discussed with staff during the exit conference.

Based on observation during the course of the survey conducted on 05/09/2017, it was determined the facility failed to maintain the means of egress doors in accordance with NFPA 101, 19.2.2 and 7.2.1. The following evidenced this:

During the walk-through with the maintenance engineer; exterior exit door on the 2nd floor at the South Exit had a door opening force greater than 15 lbs of force to open. Actual force to open the door was 29 lbs.

The deficiency has the potential to affect all occupants, including staff, residents, and visitors within the 2nd floor.

This item was discussed during the survey and again during the exit conference.

Based on observation during the course of the survey conducted on 05/09/2017, it was determined the facility failed to maintain the building construction in accordance with NFPA 101, 19.1.6.1.

The following evidenced this:

During the walk-through with the Maintenance Engineer; A. Penetrations in the wall around both ends of conduit above the entry door to the Shell Storage room was missing fire caulking and were not protected with fire caulking or other approve methods.

The construction rating deficiency has the potential to affect occupants, who might include staff, residents and visitors.

This item was discussed during the survey and again during the exit conference.