Non-compliance with NFPA 101 Construction Standards
Penalty
Summary
The facility was found to be non-compliant with NFPA 101: 19.1.6.1 during a Life Safety Code recertification survey. The West building, referred to as the Old Building, was identified as a two-story, fully sprinklered Type V (000) construction, which does not meet the required Type V (111) construction standards. The facility had been granted a CMS Time Limited Waiver (TLW) to address this issue, which is set to expire on July 1, 2025. However, as of the survey date, the facility had not yet obtained the necessary permits from the local jurisdiction, and construction had not commenced. The architect was still in the process of drawing plans, and additional smoke detectors had been installed, but these actions were insufficient to bring the building into compliance. The facility's Plan of Correction for tag K161, cited during a previous Life Safety Code survey, included reconfiguring the existing second-floor corridor ramp to achieve a compliant slope and constructing an addition to accommodate the level change. Despite having a timeline for obtaining town approval, preparing final construction drawings, and completing construction, there was no evidence that any of these milestones had been achieved at the time of the survey. The facility had contracted with an architectural/engineering firm to conduct a Fire Safety Evaluation System (FSES) after the installation, but the construction phase had not yet begun, leaving the facility out of compliance with the required safety standards.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. Pine(NAME) Center for Rehabilitation and Healthcare has an approved CMS time limited waiver that expires on 7/15/2025. 3a. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. Fire watches 2. Additional fire drills 3. Testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. Identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. Conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 6. Provide additional extinguishers 7. Properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required. 8. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. 9. Facility has developed an audit/daily rounds tracking sheet to ensure the interim life safety measures that were put into place are being completed while the deficiency exists. 10. Administrator will report any updates at the next quarterly QA meeting. 11. The Administrator is responsible for the correction of this deficiency by 4/1/2025.