Facility Fails to Meet Building Construction Type Requirements
Penalty
Summary
During a Life Safety Code Survey conducted from January 6 to January 14, 2025, it was observed that the facility, which consists of three resident sleeping floors and a basement, did not meet the required building construction type as per the 2012 edition of the National Fire Protection Association (NFPA) Life Safety Code. Specifically, the structural support members, such as the red bar joists supporting the concrete floor decks, were not protected by fire-rated material. This deficiency was noted in several locations, including near the elevators on the third and second floors, and near specific rooms on the first floor. A review of the facility's Fire Safety Evaluation System (FSES) dated March 5, 2024, indicated that the minimum compliant building construction type for the facility should be Type II (111), based on its three-story height. However, the FSES classified the building as Type II (000) due to the unprotected structural members, which do not meet the requirements for Type II (111). To comply, the structural support members must be protected from fire by a rated material or a fire-rated ceiling grid system with a fire resistance rating of at least one hour.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 It was determined that for three (first, second, and third floors) of three resident sleeping floors the facility did not meet an acceptable building construction type. Specifically, structural support members were not protected by fire rated material and the ceiling assembly was not fire rated. The facility intends to use NFPA 101A-2013 as a Guide on Alternative Approaches to Life Safety, Fire Safety Evaluation System (FSES) as an equivalency in order to comply with the cited deficiency. All other LSC deficiencies found during the survey and FSES will be corrected to ensure a passing score. The facility will be conducting a new FSES by 2/19/2025 to be performed in accordance with CMS survey and certification memo 17-15-LSC, and using the mandatory values in NFPA 101A, 2001 edition, to meet the fire safety requirements for recertification based on previous use of the FSES in conjunction with this deficiency. Results of the FSES will be shared with the regional office for review. All residents had the potential to be affected. No other life safety functions were affected. The facility will in-service the maintenance director on fire safety maintenance such as identification of any potential fire safety concerns or potential for unsafe or hazardous conditions. The Maintenance Director will be educated on the results of the FSES and on the requirement to ensure the facility is in compliance with NFPA standards. The facility also intends to maintain compliance by utilizing an FSES for equivalency as necessary for future recertifications as applicable. Audits will be conducted monthly on fire safety x4. The results of the FSES, the requirement for a passing FSES and the results of the audits will be discussed at QAPI. The Administrator/Designee is responsible for this plan.