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1) Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

The facility failed to inspect and test fire rated door assemblies throughout the facility.

Review of documentation and interview with staff determined fire rated door assemblies had not been inspected as required by NFPA 80 in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

This deficiency affected all fire rated door assemblies throughout the facility.

2) The facility failed to maintain the means of egress in accordance with Chapter 7.

During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

a) The corridor door to the Central Tub Room in the North Wing.
b) The corridor door to the Linen Storage Room near Room 109.
c) The corridor door to the Janitor Room in the East Wing.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected three (3) of numerous corridor doors in the means of egress throughout the facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 13.2.7.1, 13.3.2.1.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review and interview with staff determined the control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.