Failure to Maintain Clear Exit Discharges
Summary
The facility failed to maintain means of egress free of obstructions as required by NFPA 101 Life Safety Code (2012 Edition), Section 7.1. Observations made on January 7, 2025, revealed ice and snow buildup on the pathways from the building to the public way at multiple designated exit discharges, including those located by the employee entrance and 200 Hall, the Kitchen, and Room 105. During interviews conducted at the time of the observations, the staff confirmed the findings and acknowledged awareness that the snow and ice on the sidewalks needed to be removed. This deficiency had the potential to affect all 131 residents of the facility.
Plan Of Correction
Element 1 This deficiency was corrected by shoveling the snow and salting all exit discharge pathways from the building to the public way. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Snow/Ice audit is being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K271. This audit will be completed by making rounds around the facility. Element 4 The Snow/Ice audit is being monitored by the Administrator or designee weekly for four weeks, then every other week for four weeks, and then monthly for one month. If the facility experiences any snow or icy conditions, the audit will be performed on that day, as well as the following day to ensure safe conditions. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for three months to the Quality Assurance Performance Improvement team for review and action as necessary.
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.
Surveyors observed that the first floor therapy exit door was obstructed by ice and snow, preventing it from opening fully and resulting in an unsafe evacuation surface. The maintenance supervisor confirmed the deficiency during the inspection.
The facility did not maintain the exit discharge as per NFPA 101 standards. The exit from the Spanish Villa corridor lacked a hard-packed all-weather travel surface to the public way, potentially hindering safe evacuation. The Maintenance Director was aware of the requirement but unsure why the exit was not connected to the sidewalk. This was acknowledged by the Administrator and the Director of Maintenance.
The facility failed to maintain an emergency exit discharge near the laundry area with a hard-packed, all-weather travel surface leading to a public way. This deficiency was confirmed by the maintenance supervisor.
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.
Obstructed Exit Due to Ice and Snow Buildup
Penalty
Summary
A deficiency was identified when the first floor therapy exit door was found to have a buildup of ice and snow, which prevented the door from opening to its full width. Additionally, the exit discharge surface was not maintained in a manner that would allow for safe evacuation during an emergency. These conditions were observed during a facility inspection and were confirmed by the maintenance supervisor at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
At the time of surveyor identification, the buildup of snow and ice was removed from the first floor therapy entrance door and surface in order to permit the exit door to open to its fullest width in order to allow a safe evacuation in the event of an emergency. No further action is required. All staff will be re-educated that all surfaces, exit discharges, exit locations, and entrance accesses must be maintained free of the buildup of ice and snow in order to maintain a continuous means of egress in case of emergency. The Maintenance Director will do weekly monitoring throughout the facility to ensure that all surfaces, exit discharges, exit locations, and entrance accesses are maintained free of the buildup of ice and snow. On identification, any buildup of snow or ice will be removed.
Exit Discharge Deficiency
Penalty
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.
Emergency Exit Discharge Deficiency
Penalty
Summary
The facility failed to maintain one of its six emergency exits in compliance with NFPA 101 standards. During an observation on February 11, 2025, at 11:52 a.m., it was noted that the emergency exit discharge near the laundry area did not have a hard-packed, all-weather travel surface leading to a public way. This deficiency was confirmed through an interview with the maintenance supervisor at the same time, indicating a lapse in maintaining the required exit discharge conditions.
Plan Of Correction
1. A wheel-chair width hard packed surface will be installed at the laundry exit. This exit is not used for resident egress. 2. The other emergency exits have been audited and meet requirements. 3. A monthly check of hard packed surfaces from exit doors will be performed by the maintenance supervisor or designee to ensure that they are in good repair. 4. QAPI's Safety Committee will oversee building services for action or review. Administrator to monitor.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
