Building Construction Type Violation
Penalty
Summary
The facility was found to be in violation of building construction requirements as it was classified as a four-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered. This classification exceeds the maximum allowable height for unprotected non-combustible construction by two stories. The deficiency was identified during a document review and confirmed in an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility will be engaging a certified external auditor to conduct a comprehensive Fire Safety Evaluation System (FSES) audit. This audit will evaluate the facility's fire safety measures across all designated zones, ensuring that each area meets or exceeds the rigorous standards set forth by the FSES. A passing score for each zone is a critical requirement, as it will demonstrate the facility's commitment to maintaining a safe environment for all residents, staff, and visitors. Upon successfully achieving a passing score in all zones, the facility will become eligible for the Centers for Medicare & Medicaid Services (CMS) approved time-limited waiver. This waiver will grant the facility an extension to comply with any remaining fire safety requirements that may need additional time or adjustments, while ensuring that essential safety measures are already in place to safeguard occupants in the interim. The FSES audit will cover a range of critical fire safety aspects, including but not limited to: fire detection and alarm systems, emergency evacuation plans, fire suppression systems, staff training and preparedness, and overall compliance with both local fire codes and CMS regulations. Each zone will be meticulously assessed to identify potential vulnerabilities and areas for improvement, and the results will be used to implement necessary corrective actions. Achieving a passing score not only ensures eligibility for the CMS time-limited waiver but also reflects the facility's proactive approach to maintaining a high standard of fire safety, protecting both the health and safety of all those within the facility and mitigating the risk of fire-related incidents.