Non-compliance with Building Construction Type Requirements
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101: 19.1.6.1, which limits existing health care occupancies to specific building construction types. The nursing home building is a four-story Type II (000) construction, which exceeds the allowed two stories for this type of construction and requires complete automatic sprinkler protection. During the recertification survey, it was observed that while the elevator room and mechanical rooms on the first floor have protected steel beams, the steel beams and ceilings above the drop ceiling on floors two through four remain unprotected. The Administrator acknowledged that the facility had a time-limited waiver, which expired in 2024, and cited the facility's non-profit status as a reason for the delay in obtaining funding to complete the necessary repairs. The facility has made some progress by replacing light fixtures with compliant fire-rated fixtures and starting to replace ceiling tiles in certain areas.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 Immediate Corrective Action Brooklyn United Methodist Church Home is requesting a three (3) year waiver in order to complete the work already in progress to satisfy the K161 citation. Brooklyn United Methodist Church Home, a not-for-profit nursing facility, needed to apply for a loan in order to remedy the K161 deficiency cited in 2022 and simultaneously also applied for a two (2) year time limited waiver, also in order to complete the work necessary to comply with K161. The loan process took more than 18 months for approval, which negatively impacted the start of the project and the time limited waiver, which has since expired. Since the approval of the loan, Brooklyn United Methodist Church Home has fireproofed the steel beams in the electrical room, the mechanical room, and the boiler room. In addition, Brooklyn United Methodist Church Home has replaced all the light fixtures in the facility with compliant fire rated fixtures. Also, it is important to note that all the grids in the facility are fire rated so as to accommodate the installation of fire rated ceiling tiles. Further, the facility has purchased fire rated ceiling tiles and has installed the fire rated ceiling tiles on two (2) quadrants of the fourth (4th) floor. As such, Brooklyn United Methodist Church Home, with a time waiver extension of three (3) years, would be able to complete the required fireproofing of the facility with fire rated ceiling tiles as follows: Year 1 – Complete the Fourth (4th) and Third (3rd) floors Year 2 – Complete the Second (2nd) floor, and Year 3 – Complete the First (1st) floor II. Identification of Other Residents Brooklyn United Methodist Church Home acknowledges that the residents have the potential to be affected by this practice. The facility respectfully states that there is no additional risk to the residents as the facility is fully sprinklered throughout and smoke detectors installed that are supervised by an approved outside entity. III. Systemic Changes All staff will receive in-service education regarding the life safety issues related to this requirement. The facility will conduct an extra fire drill on each shift per quarter until the fireproof ceiling tile work is completed. Additional fire extinguishers will be maintained on each unit of the facility. The Administrator will work to secure a three (3) year waiver. IV. QA Monitoring The Administrator will monitor the status of the waiver request and any progress made in the process of continuing the work to fireproof the facility with fire rated ceiling tiles. The Administrator will provide a written report monthly to the QA committee, and said reports will be reviewed quarterly by the QAPI committee at the quarterly QAPI meetings.