Exit Discharge Deficiency
Summary
The facility failed to maintain the exit discharge in accordance with NFPA 101 standards. During an observation conducted with the Maintenance Director, it was noted that the exit door leading from the Spanish Villa corridor to the west exit discharge did not have a hard-packed all-weather travel surface extending to the public way. This deficiency could impede safe evacuation in an emergency. The Maintenance Director acknowledged the requirement but was unsure why the exit was not connected to the sidewalk. These findings were confirmed by the Administrator and the Director of Maintenance during the exit conference.
Penalty
Surveyors identified that two exit discharge sidewalks, one from a service hallway exit and another from the 100 hallway near a resident room, had large sections of concrete (about six feet each) removed and temporarily filled with gravel. These areas did not provide the required level, hard‑packed, all‑weather walking surface for exit egress as required by NFPA 101. The Director of Maintenance stated the concrete had been removed due to winter damage and confirmed the conditions at the time of the survey, with the issue having the potential to affect 29 of 64 residents.
Improper Exit Discharge Surfaces with Removed Sidewalk Sections Filled with Gravel
Penalty
Summary
Surveyors found that exit discharge walkways were not maintained in accordance with NFPA 101, 2012 Edition, affecting the required level, hard-packed, all‑weather walking surface for exit egress. During the tour, they observed that the exit discharge sidewalk from the service hallway exit had a large section of sidewalk, approximately six feet in length, removed and temporarily filled with gravel. In a separate location, the exit discharge sidewalk from the 100 hallway near room 106 also had an approximately six‑foot section of sidewalk removed and similarly filled with gravel. These conditions did not meet the Life Safety Code requirements for exit discharge surfaces to be level, unobstructed, and compliant with provisions related to changes in elevation. The Director of Maintenance reported that both sidewalk sections had been removed due to winter damage and stated that new concrete would be poured when weather permitted. At the time of observation, the temporary gravel fill remained in place, and the Director of Maintenance verified the surveyors’ findings. The deficient practice had the potential to affect 29 of the facility’s 64 residents by compromising the required exit discharge conditions.
Plan Of Correction
This plan of correction does not constitute an admission to any of the allegations contained within the Statement of Deficiencies. Rather, this plan of correction has been prepared and executed because state and federal law require it, and not because Pine Grove Healthcare Center agrees with these citations. The facility maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents. This plan of correction is not meant to establish any standard of care, contract, obligation or position, and Pine Grove Healthcare Center reserves all right to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. This plan of correction shall also operate as the facility's credible allegation of compliance. Please accept 04/15/2026 as our date of compliance. K0271: The facility will continue to ensure exit egress walkways are in accordance with the LSC, 2012 Edition Sections 7.1.10.1 and 7.7.3.4. On 4/15/2026 facility had new concrete poured and repairs completed to both discharge sidewalks. Discharge sidewalk leading from the service hallway and discharge sidewalk leading from the 100 hallway are in compliance. Pictures of the work completed and the scope of work/invoice from the concrete company are attached.
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