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The facility failed to ensure the corridor doors were provided with hardware to keep the door closed.

Observation determined the latching hardware on the west leaf of the Scrub Room door was equipped with manual flush latches rather than the required automatic flush latching hardware.

The facility failed to ensure oxygen supply piping and all shut-off valves were identified with markings/labels. NFPA 99, 4-3.1.2.13.

Observation determined the piping for the oxygen supply in the Oxygen Storage Room had no markings or labels applied to the piping to indicate the content of the gas line.

1) Means of egress must have exit and directional signs with continuous illumination visible from any direction of exit access. 7.10, 39.2.10.

Observation determined the facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. Three (3) of three (3) battery-powered exit lights failed to illuminate when tested.

2) A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test shall be conducted for a 90-minute duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction. 7.9, 39.2.9.

The facility failed to ensure testing of emergency battery-powered lights was completed.

Observation determined three (3) of four (4) battery-powered emergency lights failed to illuminate when tested. No documentation was available for the testing of the battery-powered lights.

3) Portable fire extinguishers shall be provided in every business occupancy. 9.7.4.1, NFPA 10, 39.3.5.

Portable fire extinguisher type, size and location must meet NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 indicates that portable fire extinguishers must be within 75 feet of travel from any location in the building.

a) The facility failed to provide fire extinguishers within 75 feet travel distance to all locations within the building.

Observation determined a fire extinguisher was not provided to protect the west portion the facility.

b) The facility failed to provide the proper type of fire extinguishers.

Observation determined the only fire extinguisher in the building was rated for Class B and Class C fires.

4) Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors. 39.3.1.2.

The facility failed to provide a protected opening from the basement storage area to the main floor business occupancy.

Observation determined there was no vertical separation from the basement storage area to the main floor business occupancy.

5) The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies. 39.3.2

Observation determined:

a) The basement storage area was not separated from the main floor business occupancy with a one-hour fire rated assembly.

b) The gas furnace on the main floor was not separated from the rest of the building with a one-hour fire rated assembly.

The facility failed to ensure the corridor doors were provided with hardware to keep the door closed.

Observation determined the latching hardware on the west leaf of the Scrub Room door was equipped with manual flush latches rather than the required automatic flush latching hardware.

The facility failed to ensure oxygen supply piping and all shut-off valves were identified with markings/labels. NFPA 99, 4-3.1.2.13.

Observation determined the piping for the oxygen supply in the Oxygen Storage Room had no markings or labels applied to the piping to indicate the content of the gas line.

1) Means of egress must have exit and directional signs with continuous illumination visible from any direction of exit access. 7.10, 39.2.10.

Observation determined the facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. Three (3) of three (3) battery-powered exit lights failed to illuminate when tested.

2) A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test shall be conducted for a 90-minute duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction. 7.9, 39.2.9.

The facility failed to ensure testing of emergency battery-powered lights was completed.

Observation determined three (3) of four (4) battery-powered emergency lights failed to illuminate when tested. No documentation was available for the testing of the battery-powered lights.

3) Portable fire extinguishers shall be provided in every business occupancy. 9.7.4.1, NFPA 10, 39.3.5.

Portable fire extinguisher type, size and location must meet NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 indicates that portable fire extinguishers must be within 75 feet of travel from any location in the building.

a) The facility failed to provide fire extinguishers within 75 feet travel distance to all locations within the building.

Observation determined a fire extinguisher was not provided to protect the west portion the facility.

b) The facility failed to provide the proper type of fire extinguishers.

Observation determined the only fire extinguisher in the building was rated for Class B and Class C fires.

4) Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors. 39.3.1.2.

The facility failed to provide a protected opening from the basement storage area to the main floor business occupancy.

Observation determined there was no vertical separation from the basement storage area to the main floor business occupancy.

5) The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies. 39.3.2

Observation determined:

a) The basement storage area was not separated from the main floor business occupancy with a one-hour fire rated assembly.

b) The gas furnace on the main floor was not separated from the rest of the building with a one-hour fire rated assembly.