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.