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Based on observation and interview, it was determined the facility failed to maintain exit access in two instances, affecting two of four stairways.

Findings include:

1. Observation on October 25, 2023, revealed the following stair towers were not in compliance with NFPA 101 section 7.7.3:

a) 9:10 a.m., stairway T4 on the first floor;
b) 9:45 a.m., stairway T2 on the first floor.

The exit discharge is located on the first floor and the stairs continue uninterrupted to the basement.

Interview with the Facility Director of Quality and Risk Assesment and Maintenance Director on October 25, 2023, at 11:30 a.m., confirmed the building egress deficiency.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on October 24, 2023, at 11:32 a.m., revealed the facility lacked documentation for an annual load bank test for the emergency generator.

Interview with the Facility Director of Quality and Risk Assesment and Maintenance Director on October 25, 2023, at 11:30 a.m., confirmed the facility lacked the annual generator load testing documentation, at the time of the survey.

Based on observation and interview, it was determined the facility failed to properly maintain oxygen storage in one instance, affecting one of nine smoke compartments.

Findings include:

1. Observation on October 25, 2023, at 10:20 a.m., revealed an unsecured oxygen cylinder on the floor in the ice room across from room 112, on the first floor.

Interview with the Facility Director of Quality and Risk Assesment and Maintenance Director on October 25, 2023, at 11:30 a.m., confirmed the unsecured oxygen cylinder.