Deficiencies in Means of Egress and Ramp Compliance
Penalty
Summary
The facility was found to have deficiencies related to the means of egress as per the NFPA 101 Life Safety Code, 2012 Edition. Specifically, a ramp located on the second floor between the Old Building and the New Wing did not comply with the dimensional criteria set forth in the code. The ramp had a slope of 15 inches in height over a length of 10.3 feet, which exceeds the permissible slope of 1 inch in 8 feet. At the time of the survey, no work had been observed to address this issue, despite a time-limited waiver being granted to correct it. Additionally, a corridor on the first floor, adjacent to the Administrator's office, was found to be reduced to 40 inches in clear width, which is below the required minimum of 48 inches for corridors serving as means of egress from patient sleeping rooms. This corridor served as exit access for five occupied resident sleeping rooms and one nurse office. The arrangement of emergency exits at the end of this corridor did not comply with the Life Safety Code requirements, as they were located opposite each other with a distance of approximately 28 feet between them, potentially allowing both exits to be blocked by a single fire or emergency condition. The facility had been granted a CMS Time Limited Waiver to address these issues, set to expire on July 1, 2025. However, at the time of the survey, the facility had not demonstrated substantial progress in addressing the deficiencies. The owner stated that plans were being drawn by an architect, but permits had not yet been obtained, and no construction work had commenced. The facility's Plan of Correction included contracting with an architectural firm to reconfigure the ramp and modify the corridor width, but there was no evidence of progress on these plans.
Plan Of Correction
Plan of Correction: Approved April 22, 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 will require a time limited waiver for three years, ending 2/7/2028, to complete construction to widen the corridor to 48 inches minimum. The facility is currently investigating means to widen the existing first floor corridor as it is located between a masonry chimney and apparent bearing wall. The existing LRA shall be updated accordingly to include this work. It’s anticipated that the LRA will be updated by 8/7/2025. Following LRA modification approval, construction drawings will be prepared by 2/7/2026. Local approvals are expected to be obtained by 8/7/2026. Construction is anticipated to be complete by 10/7/2027. Signoffs are anticipated to be complete by 2/7/2028. 3b. While the facility has a time limited waiver in place, upon further review of the existing conditions during production of construction drawings, the Architect determined that the existing ramp slope is compliant. An existing ramp is permitted to have a maximum slope of 1:8, or 12.5%. The existing ramp was recorded to measure 15 inches in height and 10.3 feet in length. The existing ramp slope is calculated to be 12.14%, which is less than 12.5% maximum permitted. 3c. 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. During construction, facility will perform frequent observations of the work areas to monitor resident safety. 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.