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Based on observation and interview, the facility failed to maintain the building construction type of the facility. This deficient practice could affect all occupants within the facility.

Findings include:

Based on observation on 10/18/2022 during a tour of the facility from 12:45 p.m. to 1:50 p.m. with the Facilities Director, the concrete ceiling in the boiler room had a PVC pipe penetrating through a three inch in diameter hole leading up to the second floor of the facility. Based on interview at the time of observation, the Facilities Director agreed there was an open vertical penetration through the concrete ceiling, and he would get the hole filled in as soon as possible.

This finding was reviewed with the Facilities Director at the exit conference.

1. Based on observation and interview, the facility failed to ensure 1 of 1 portable fire extinguishers in the dosing room were installed in accordance with NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition. Section 6.1.3.4 states portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means. (1) Securely on a hanger intended for the extinguishers. (2) In the bracket supplied by the extinguisher manufacture. (3) In a listed bracket approved for such purpose. (3) In a cabinet or wall recess. This deficient practice could affect staff in the dosing room.

Findings include:

Based on observations during a tour of the facility with the Facilities Director on 10/18/22 at 1:35 p.m. the ABC portable fire extinguisher located in the dosing room was sitting on the floor. Based on interview at the time of observation, the Facilities Director agreed the extinguisher was sitting on the floor and not mounted.

This finding was reviewed with the Facilities Director at the exit conference.


2. Based on observation and interview, the facility failed to ensure all portable fire extinguishers were given maintenance at periods not more than one year apart. NFPA 10, the Standard for Portable Fire Extinguishers, at Section 7.3.1.1.1 requires that fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification. Section 3.3.15 defines extinguisher maintenance as a thorough examination of the fire extinguisher that is intended to give maximum assurance that a fire extinguisher will operate effectively and safely and to determine if physical damage or condition will prevent its operation, if any repair or replacement is necessary, and if hydrostatic testing or internal maintenance is required. Section 7.3.3 states each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed, identifies the person performing the work, and identifies the name of the agency performing the work. This deficient practice could affect staff.

Findings include:

Based on an observation with the Facilities Director on 10/18/2022 at 1:35 p.m., the tag on the ABC fire extinguisher in the dosing room had an annual inspection date of May 2020. Based on interview at the time of observation, the Facilities Director agreed the fire extinguisher's annual inspection was past due.

This finding was reviewed with the Facilities Director at the exit conference.