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Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 05/02/2022 at 2:22 p.m., the door leading to the autoclave room was inspected. The door was fitted with a self-closure device and failed to close and positively latch when exercised.

2. During an observation on 05/02/22 at 2:23 p.m., the door leading to the central supply room was inspected. The door was fitted with a self-closure device and failed to close and positively latch when exercised.

Based on observation, the facility failed to prevent the use of an enclosed exit stairway for storage purposes per NFPA 101-2012, Sections 7.1.3.2.3 and 7.2.2.5.3;

Findings include:

1. During an observation on 05/02/2022 at 2:44 p.m., the stairwell to the basement was inspected. There were several boxes being stored under the stairwell stairs. Stairwells cannot have any items stored or interrupting the egrees in the stairwell.

Based on observation and record review, the facility failed to document monthly standpipe gauge readings per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1.

Findings include:

1. Record review of facility documentation for the automatic sprinkler system on 05/02/22, reflected the facility failed to document monthly pressure gauge checks on the wet system.