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Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.1.

Findings include:

1. During an observation on 9/5/23 at 2:11 p.m., the Centennial courtyard west exit was inspected. The path of egress was blocked by construction material. The facility was having some outside work done, but the contractors were blocking the exit path with the building material.

Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3 and 7.2.1.6.2.

Findings include:

1. During an observation on 9/5/23 at 1:23 p.m., the CT area was inspected. There was an illuminated exit sign guiding occupants of the area to a magnetically locked door. The door lacked delay egress or any other special locking arrangement required to exit the area when magnetic locks are present.

Based on observation, the facility failed to ensure there was a level path of egress to the public way in accordance with NFPA 101, 2012 Edition, Section 7.1.7.

Findings include:

1. During an observation on 9/5/23 at 1:35 p.m., the acute hall exit path to the public way was inspected. At the end of the sidewalk there was a 5 inch step down to the public way. The path to the public way cannot be unlevel by more than 1/4".

Based on observation, the facility failed to assure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 9/5/23 at 1:31 p.m., a resident room titled "temporary storage" was inspected. The facility places covid supplies in the room, using the room as a storage area. The room is over 50 square feet and it lacked the necessary self-closing device on the corridor door.

2. During an observation on 9/5/23 at 1:31 p.m., room 212 A/B was inspected. The room was being used as a storage area. The room is over 50 square feet and it lacked the necessary self-closing device on the corridor door.

Based on record review and observation, the facility failed to ensure spare sprinklers were available in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5, and

Findings Include:

1. During an observation 9/5/23 at 1:48 p.m., the spare sprinkler head box at the stand pipe was found to be missing directional replacement sprinkler heads. The facility utilized some directional heads on the system, they did not have any spares for the type of head being utilized.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 9/5/23 at 1:05 p.m., the OR foyer was inspected. There was a portable extinguisher in the room which was blocked from access by a medical equipment cart in the room.

Based on record review, the facility failed ensure all employees were kept informed with respect to their duties during a fire drill per NFPA 101. 2012 Edition, section 19.7.1.2.

Findings include:

1. Review of the facility fire drills for 2021 and 2022 reflected the facility lacked staff signatures for many documented fire drills performed at the facility during the years of 2022 and 2023.

Based on observations, the facility failed to maintain and protect electrical wiring energized above 50 volts in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110.27.

Findings include:

1. During an observation on 9/5/23 at 1:10 p.m., OR room 1 was inspected. There was a junction box for a wall mounted clock in the room with the wiring and connectors left unprotected from being touched or damaged.