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Based on observations during the survey walk of the facility on the afternoon of 05/11/2016, while being accompanied by the Director of Nursing, the facility failed to provide the direction of the egress path. No exit sign existed at the smoke compartment barrier doors, near room 429.

Based on observations during the survey walk of the facility on the afternoon of 05/11/2016, while being accompanied by the Director of Nursing, the facility failed to maintain the smoke barrier. Astragal was wearing out at smoke barrier doors ' meeting edges therefore smoke may penetrate between doors ' leaves gap.
NFPA 101, 2003: 18.3.7.10 ..... Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.
Also applicable is NFPA 101: 8.3.3.1 .... Where openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies .....and their accompanying hardware .....

Based on review of records during the survey of the facility on the morning of 05/11/2016, with the Director of Nursing, the facility failed to provide documents for biomedical equipment. Facility must initiate a log to retain these records. The AED was tested 02/2013.



Based on observations during the survey walk of the facility on the afternoon of 05/11/2016, while being accompanied by the Director of Nursing, the facility failed to maintain a physical environment that protects the health and safety of patients. In the seclusion patient toilet rom, a heater was above the toilet and light lenses were missing at the light fixtures.



Based on review of records during the survey of the facility on the morning of 05/11/2016, with the Director of Nursing, the facility to ensure that disaster drills were signed by staff. At least one semi-annual drill shall rehearse mass casualty response for emergency services, disaster receiving stations, or both and be logged in with signatures of those attending.

Based on observations during the survey walk of the facility on the afternoon of 05/11/2016, while being accompanied by the Director of Nursing, the facility failed to provide the direction of the egress path. No exit sign existed at the smoke compartment barrier doors, near room 429.

Based on observations during the survey walk of the facility on the afternoon of 05/11/2016, while being accompanied by the Director of Nursing, the facility failed to maintain the smoke barrier. Astragal was wearing out at smoke barrier doors ' meeting edges therefore smoke may penetrate between doors ' leaves gap.
NFPA 101, 2003: 18.3.7.10 ..... Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.
Also applicable is NFPA 101: 8.3.3.1 .... Where openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies .....and their accompanying hardware .....

Based on review of records during the survey of the facility on the morning of 05/11/2016, with the Director of Nursing, the facility failed to provide documents for biomedical equipment. Facility must initiate a log to retain these records. The AED was tested 02/2013.



Based on observations during the survey walk of the facility on the afternoon of 05/11/2016, while being accompanied by the Director of Nursing, the facility failed to maintain a physical environment that protects the health and safety of patients. In the seclusion patient toilet rom, a heater was above the toilet and light lenses were missing at the light fixtures.



Based on review of records during the survey of the facility on the morning of 05/11/2016, with the Director of Nursing, the facility to ensure that disaster drills were signed by staff. At least one semi-annual drill shall rehearse mass casualty response for emergency services, disaster receiving stations, or both and be logged in with signatures of those attending.