Deficiency in Fire Exit Compliance
Summary
The facility was found to be non-compliant with the NFPA 101 requirements for the number of exits per story and compartment. During a document review and interview on December 16, 2024, it was determined that the facility lacked two approved exits that are remote from each other for each floor or fire section of the building. The existing exit strategy relied on a communicating stairway located in the center of the building, which does not meet the requirement for distinct egress paths. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. A follow-up onsite revisit on February 5, 2025, confirmed that the issue had not been resolved, as the facility still lacked acceptable fire exits. The facility acknowledged the deficiency and indicated that they are working to obtain a Fire Safety Evaluation System (FSES) to address the issue.
Penalty
A surveyor observed that the basement had only a single exit, and the Administrator confirmed the lack of at least two remote exits, resulting in noncompliance with NFPA 101 requirements for exit accessibility in smoke compartments.
Surveyors found that the facility basement, which houses the laundry, employee break room, maintenance office, boiler room, storage, electrical room, and employee bathroom/locker room, had only one exit instead of the two required by NFPA 101. This deficiency was confirmed by interviews with facility leadership and could affect about 10 occupants in an emergency.
A deficiency was identified when it was observed that the basement maintenance shop and mechanical room had only one exit, failing to meet the requirement for at least two remote and accessible exits from every part of every story and smoke compartment. This was confirmed by the Maintenance Director and could affect three occupants in the event of a fire.
The facility was found to lack two acceptable emergency exits in the basement, as the north exit is a communicating stair that does not lead to an exterior exit discharge. This deficiency was confirmed by the Administrator and Maintenance Director.
The facility failed to comply with NFPA 101 requirements by not providing at least two remote exits for two of its smoke compartments. Observations revealed that the 2nd floor Annex and the basement lacked the necessary exits. This was confirmed by the Maintenance Manager.
The facility failed to provide two acceptable exits from each floor of the Center Building, affecting the entire building component. All three floors lacked a second acceptable means of exiting, with existing routes consisting exclusively of horizontal exits into adjacent healthcare buildings, not meeting NFPA 101 standards.
Failure to Provide Required Number of Exits in Basement
Penalty
Summary
During an observation conducted on July 29, 2025, at 11:50 AM, it was found that the basement of the facility had only a single exit. This was confirmed in an interview with the Administrator at the same time, who acknowledged that the basement did not have at least two exits remote from each other. The deficiency affects one of two smoke compartments within the component, as the facility failed to provide not less than two exits, remote from one another, for each floor as required by NFPA 101 standards.
Failure to Provide Required Number of Basement Exits
Penalty
Summary
Surveyors observed that the facility failed to provide the required number of exits from the basement, as mandated by NFPA 101, sections 19.2.4.1 through 19.2.4.4. During an inspection, it was found that there was only one exit available from the basement, which is occupied by the laundry area (including a linen chute from the first floor), employee break room, maintenance office, boiler room, storage room, electrical room, and employee bathroom/locker room. This observation was confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of the survey. Approximately 10 occupants could be affected by this deficiency in the event of a fire emergency, as the basement does not meet the requirement for at least two remote and accessible exits from every story and compartment.
Plan Of Correction
Element 1 No residents were identified. Residents do not have access to the basement. Staff are aware of the emergency exit. Element 2 All other areas where residents have access to, have required exits. Element 3 The facility administrator has contracted with the LSC Specialist to conduct a Fire Safety Evaluate System (FSES) survey for a waiver request. The FSES will be completed on 7/18/2025 and forwarded to Life Safety for a waiver request. Element 4 Audit will be completed weekly regarding accessible exits on every story. Results will be reviewed with the Administrator and brought to monthly QAPI for review and recommendations. Administrator is responsible for compliance.
Insufficient Exits in Basement Maintenance and Mechanical Areas
Penalty
Summary
The facility failed to provide at least two remote and accessible exits from every part of every story and smoke compartment, as required by regulations. During an observation on May 21, 2025, it was found that the basement maintenance shop and mechanical room had only one exit. This observation was confirmed by the Maintenance Director at the time of discovery. This deficiency could affect three occupants in the event of a fire, as noted in the report. No additional information about the medical history or condition of the affected individuals was provided.
Facility Lacks Two Acceptable Exits in Basement
Penalty
Summary
The facility failed to provide two acceptable exits, located remotely from one another, affecting one of two floors of the building. During a document review on March 17, 2025, it was revealed that the basement level of the facility lacked two acceptable emergency exits that are located remotely from each other. Specifically, the north exit from the basement is a communicating stair and does not lead to an exterior exit discharge. This deficiency was confirmed during an interview at the exit conference with the Administrator and Maintenance Director on the same day, where it was acknowledged that the basement level lacked two acceptable exits.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Non-Compliance with NFPA 101 Exit Requirements
Penalty
Summary
The facility was found to be non-compliant with the NFPA 101 requirement for providing at least two exits, remote from each other, for each story and smoke compartment. During an observation conducted on February 11, 2025, between 11:30 AM and 1:30 PM, it was noted that two of the seven smoke compartments within the component lacked the required exits. Specifically, the 2nd floor Annex and the basement did not have two exits that were remote from each other. This deficiency was confirmed through an interview with the Maintenance Manager at 1:30 PM on the same day.
Facility Lacks Second Acceptable Exit from Center Building
Penalty
Summary
The facility failed to provide two acceptable exits from each floor of the Center Building, affecting the entire building component. During a document review on January 30, 2025, it was observed that all three floors of the Center Building lacked a second acceptable means of exiting. The existing exit routes consisted exclusively of horizontal exits into adjacent healthcare buildings, which does not meet the requirement for two distinct egress paths from each story and smoke compartment as per NFPA 101 standards.
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