Report to Congressional Requesters

United States Government Accountability Office

GAO 

July 2004 NURSING HOME 

FIRE SAFETY 

Recent Fires Highlight 

Weaknesses in 

Federal Standards and 

Oversight 

GAO-04-660 
www.gao.gov/cgi-bin/getrpt?GAO-04-660.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Kathryn G. 

Allen at (202) 512-7118. 

Highlights of GAO-04-660, a report to 

congressional requesters 

July 2004

NURSING HOME FIRE SAFETY 

Recent Fires Highlight Weaknesses in 

Federal Standards and Oversight 

Cost has been a barrier to CMS requiring sprinklers for all older nursing 

homes even though sprinklers are considered to be the single most effective 

fire protection feature. There has never been a multiple-death fire in a fully 

sprinklered nursing home and sprinklers are now required in all new 

facilities. The decision to allow older, existing facilities to operate without 

sprinklers is now being reevaluated in light of the 2003 nursing home fires. 

Although the amount is uncertain, sprinkler retrofit costs remain a concern, 

and the nursing home industry endorses a transition period for homes to 

come into compliance with any new requirement. If retrofitting is eventually 

required, it is likely to be several years before implementation begins. 

The nursing home fires in Hartford and Nashville revealed weaknesses in 

federal nursing home fire safety standards for unsprinklered facilities. For 

example, federal standards did not require either home to have smoke 

detectors in resident rooms where the fires originated, and the fire 

department investigations suggested that their absence may have delayed 

the notification of staff and activation of the buildings’ fire alarms. In light of

inadequate staff response to the Hartford fire, the degree to which the 

standards rely on staff to protect and evacuate residents may be unrealistic. 

Moreover, many unsprinklered homes are not required to meet all federal 

fire safety standards if they obtain a waiver or are able to demonstrate that 

compensating features offer an equivalent level of fire safety. However, 

some of these exemptions raise a concern about whether resident safety was 

adequately considered. For example, a large number of unsprinklered 

homes in at least two states have waivers of standards designed to prevent 

the spread of smoke during a fire. 

State and federal oversight of nursing home fire safety is inadequate. 

Postfire investigations by Connecticut and Tennessee revealed deficiencies 

that existed, but were not cited, during prior surveys. For example, a survey 

conducted of the Hartford home 1 month prior to the fire did not uncover 

the lack of fire drills on the night shift and, on the night the fire occurred, the 

staff failed to implement the home’s fire plan. The survey was conducted 

during the daytime and relied on inaccurate documentation that all shifts 

were conducting fire drills. On the other hand, Tennessee’s postfire 

investigation failed to explore staff response, a deficiency cited on the 

home’s four prior surveys. The limited number of federal fire safety 

assessments, though inconsistent with the statutory requirement for federal 

oversight surveys, nonetheless demonstrate that state surveyors either miss 

or fail to cite all fire safety deficiencies. CMS provides limited oversight of 

state survey activities to address these fire safety survey concerns. In 

general, CMS (1) lacks basic data to assess the appropriateness of 

uncorrected deficiencies, (2) infrequently reviews state trends in citing fire 

safety deficiencies, and (3) provides insufficient oversight of deficiencies 

that are waived or that homes do not correct because of asserted 

compensating fire safety features. 

In 2003, 31 residents died in 

nursing home fires in Hartford, 

Connecticut, and Nashville, 

Tennessee. Federal fire safety 

standards enforced by the Centers 

for Medicare & Medicaid Services 

(CMS) did not require either home 

to have automatic sprinklers even 

though they have proven very 

effective in reducing the number of 

multiple deaths from fires. GAO 

was asked to report on (1) the 

rationale for not requiring all 

homes to be sprinklered, (2) the 

adequacy of federal fire safety 

standards for nursing homes that 

lack automatic sprinklers, and 

(3) the effectiveness of state and 

federal oversight of nursing home 

fire safety. 

GAO is making several 

recommendations to the 

Administrator of CMS to 

(1) improve oversight of nursing 

home fire safety, such as reviewing 

the appropriateness of exemptions 

to federal standards granted to 

unsprinklered facilities and 

(2) strengthen the fire safety 

standards and ensure thorough 

investigations of any future 

multiple-death nursing home fires 

in order to reevaluate the adequacy 

of fire safety standards. CMS 

concurred with GAO’s 

recommendations. 
Page i GAO-04-660 Nursing Home Fire Safety 

Letter 1

Results in Brief 3

Background 6

Despite Effectiveness, Cost Has Been a Barrier to Requiring 

Sprinklers for All Older Nursing Homes 13

Federal Fire Safety Requirements for Unsprinklered Nursing 

Homes Are Weak 17

State and Federal Oversight of Nursing Home Fire Safety Is 

Inadequate 26

Conclusions 39

Recommendations for Executive Action 40

Agency, State, and NFPA Comments and Our Evaluation 41

Appendix I Percentage of Surveyed Nursing Homes Cited with 

Fire Safety Deficiencies on Their Most Recent 

Surveys, by State 43 

Appendix II Federal Comparative Survey Results for Fiscal Year 

2003—Examples of Fire Safety Deficiencies Missed 

or Not Cited 45 

Appendix III Comments from the Centers for Medicare & Medicaid 

Services 49 

Tables 

Table 1: Scope and Severity of Deficiencies Identified during 

Nursing Home Surveys 9

Table 2: Key Facts about the Hartford and Nashville Nursing Home 

Fires 12

Table 3: Sprinkler Requirements for Existing Nursing Homes, by 

Construction Type 14

Table 4: Potential Weaknesses in Federal Standards Contributing 

to Multiple-deaths in Hartford and Nashville Nursing Home 

Fires 18

Contents 
Page ii GAO-04-660 Nursing Home Fire Safety 

Table 5: Violations of Federal Standards in Hartford and Nashville 

Nursing Home Fires Not Identified during Prior Surveys 28

Table 6: States with Large Proportions of Current Fire Safety 

Surveys Conducted in 2 hours or Less 34

Table 7: Comparison of the Number and Type of Federal 

Monitoring Surveys Including Quality-of-Care and Fire 

Safety Standards, Fiscal Year 2003 36

Figures 

Figure 1: How Nursing Homes May Address Fire Safety 

Deficiencies 10

Figure 2: Percentage of Nursing Homes Reported to Have Fire 

Safety Deficiencies on Their Most Recent Surveys in 

States with at Least 100 Homes 31

Abbreviations 

AHCA American Health Care Association 

CMS Centers for Medicare & Medicaid Services 

FSES Fire Safety Evaluation System 

HVAC heating, ventilating, and air-conditioning system 

NFPA National Fire Protection Association 

OSCAR On-Line Survey, Certification, and Reporting system 

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Page 1 GAO-04-660 Nursing Home Fire Safety 

July 16, 2004 

The Honorable Charles E. Grassley 

Chairman 

Committee on Finance 

United States Senate 

The Honorable Bill Frist, MD 

United State Senate 

Two deadly nursing home fires in 2003 focused considerable attention on 

the safety of the nation’s 1.5 million nursing home residents, a highly 

vulnerable population of elderly and disabled individuals. The 

development and enforcement of fire safety standards for nursing homes 

is critical because many residents have restricted mobility that may be 

accompanied by cognitive impairments, conditions that can limit their 

ability to escape if a fire should occur. To ensure the health and safety of 

nursing home residents, the federal government adopts and enforces 

standards that all homes serving Medicare or Medicaid beneficiaries must 

meet, and state survey agencies conduct periodic inspections, known as 

surveys, to determine whether the standards are being met.1

 The most 

recent data show that an average of about 2,300 of the nation’s 

approximately 16,300 nursing homes reported a structural fire each year 

from 1994 through 1999 and that annually, the average number of firerelated nursing home deaths nationwide was about five.2

 Over this same 

time frame, one multiple-death nursing home fire resulted in three 

fatalities.3

 In contrast, the fire-related death toll in 2003 was considerably 

higher—a total of 31 residents died in the nursing home fires in Hartford, 

Connecticut (16 deaths), and Nashville, Tennessee (15 deaths). Neither 

home was required to have an automatic sprinkler system even though 

 1

Federal fire safety standards for nursing homes are based on requirements developed and 

periodically updated by the National Fire Protection Association, a nonprofit membership 

organization. 

2

While cooking and dryers were the leading causes of fires, resident deaths were largely 

due to smoking, and resident rooms were the leading areas of fire origin. These data, 

published by the National Fire Protection Association, are based on fires reported to 

municipal fire departments. 

3

Fire safety experts often focus on fires that result in multiple-deaths (three or more) 

because they may suggest the need to reevaluate the adequacy of the standards. 

United States Government Accountability Office

Washington, DC 20548 
Page 2 GAO-04-660 Nursing Home Fire Safety 

such systems have proven very effective in reducing the number of 

multiple deaths from fires. Federal fire safety standards do not require 

sprinklers in existing nursing homes of certain noncombustible 

construction, and it is estimated that 20 to 30 percent of nursing homes 

nationwide lack full automatic sprinkler protection. 

The large number of resident deaths in the Hartford and Nashville fires 

raised serious questions about nursing home fire safety. You asked us to 

report on (1) the rationale for not requiring all nursing homes to have 

sprinklers and the status of any initiatives to change that requirement; 

(2) the adequacy of federal fire safety standards for, and their application 

to, nursing homes that lack automatic sprinkler systems; and (3) the 

effectiveness of state and federal oversight of nursing home fire safety. To 

do so, we used information related to the Hartford and Nashville fires as a 

context for addressing these broader issues. In responding to the first two 

questions, we reviewed federal fire safety standards with a focus on why 

some homes are not required to install sprinklers and on features in such 

homes that compensate for the lack of sprinklers. We discussed the 

process for developing the standards and their evolution over time with 

officials from the Centers for Medicare & Medicaid Services (CMS), the 

federal agency responsible for managing Medicare and Medicaid and 

overseeing compliance with federal nursing home standards, including 

those related to fire safety; the National Fire Protection Association 

(NFPA), a nonprofit membership organization that develops and 

advocates scientifically based consensus standards regarding fire, 

building, and electrical safety;4

 associations representing nursing homes, 

state fire marshals, and the sprinkler industry; and officials in selected 

states that exceed federal requirements because nursing homes were 

required to install automatic sprinkler systems. CMS and the associations 

we contacted are either NFPA members or are represented on one of its 

technical committees that develops criteria for the standards. NFPA 

shared with us data it collects on significant structural fires, including 

those in nursing homes. We also reviewed multiple investigative reports on 

the Hartford and Nashville fires conducted by state and local fire marshals 

and state survey agencies to determine if they identified any weaknesses 

 4

Both NFPA and CMS refer to fire safety standards as the “Life Safety Code.” The purpose 

of the code is to provide minimum requirements for the design, operation, and maintenance 

of buildings and structures for minimizing danger to life from fire, including smoke, fumes, 

or panic. The federal code is based on NFPA’s life safety code, known as NFPA 101. 

Throughout this report, we use the term federal fire safety standards when referring to the 

Life Safety Code. 
Page 3 GAO-04-660 Nursing Home Fire Safety 

in the standards for unsprinklered homes. Because nursing homes are 

allowed to operate in some circumstances without correcting all 

deficiencies identified during state surveys, we worked with CMS to 

identify states having both a high proportion of unsprinklered nursing 

homes and certain uncorrected deficiencies that could contribute to the 

spread of smoke—a factor that often results in multiple fire fatalities. We 

then examined the rationale for exemptions from federal standards for a 

sample of uncorrected deficiencies in unsprinklered homes in four states. 

To assess state and federal oversight of nursing home fire safety, we 

reviewed the investigations of the Hartford and Nashville fires conducted 

by the respective state survey agencies; examined the fire safety records of 

the two homes, including the most recent surveys prior to the fires; and 

discussed oversight issues with officials in both states and their respective 

CMS regional offices. In addition, we analyzed data in CMS’s On-Line 

Survey, Certification, and Reporting (OSCAR) system on the results of 

periodic state nursing home surveys for compliance with federal fire safety 

requirements. We discussed state fire safety compliance with officials at 

CMS headquarters and in each of CMS’s 10 regional offices and collected 

data on CMS oversight activities, such as the results of federal monitoring 

surveys, which are conducted to assess the adequacy of state survey 

activities. We conducted electronic testing of the OSCAR data for 

completeness and to identify obvious errors. CMS officials generally 

recognize OSCAR data to be reliable, and throughout the course of our 

work, we shared our analysis of OSCAR data with CMS officials at both 

headquarters and the regions to ensure that the data accurately reflected 

state fire safety activities. Based on these reliability checks, we judged 

OSCAR to be appropriate for our work. We conducted our review from 

November 2003 through July 2004 in accordance with generally accepted 

government auditing standards. 

Although the substantial loss of life in the Hartford and Nashville fires 

could have been reduced or eliminated by the presence of properly 

functioning automatic sprinkler systems, the potential retrofit cost has 

been a barrier to CMS requiring them for all homes nationwide. Older 

homes, such as the Hartford and Nashville facilities (built in 1970 and 

1967, respectively), are generally allowed to operate without sprinklers if 

they are constructed with noncombustible materials that have a certain 

minimum ability to resist fire. According to CMS, the decline in multipledeath fires after the adoption of NFPA fire safety standards in 1971 and 

their subsequent enforcement suggested that the estimated cost to retrofit 

all older nursing homes nationwide outweighed the benefit. This position 

Results in Brief 
Page 4 GAO-04-660 Nursing Home Fire Safety 

is being reevaluated, however, because of the 2003 nursing homes fires, 

and the nursing home industry has indicated its support for requiring older 

homes to install sprinklers. Industry officials believe that there must be a 

discussion about how to pay for the cost of installing sprinklers and a 

transition period for homes to come into compliance. It is likely to be 

several years before all older homes would be required to install sprinklers 

because of the process and time required for affected stakeholders—

including NFPA, CMS, and the nursing home industry—to develop a 

consensus on and implement such a standard. 

The recent nursing home fires in Hartford and Nashville revealed 

weaknesses in federal fire safety standards and their application in 

unsprinklered facilities. For example, even in the absence of sprinklers, 

the standards do not require smoke detectors in most nursing homes, yet 

investigations of the Hartford and Nashville fires suggested that the lack of 

smoke detectors in resident rooms where the fires started may have 

delayed staff response and activation of the buildings’ fire alarms. 

Moreover, walls between resident rooms are not required to resist the 

passage of smoke, yet residents in rooms adjacent to where the fires 

originated died from smoke inhalation. In addition, inadequate staff 

response contributed to the loss of life in the Hartford fire, suggesting that 

the standards’ reliance on staff response as a key component of fire 

protection may not always be realistic, particularly in an unsprinklered 

facility. CMS did not conduct its own independent review of the two fires, 

thus forgoing an opportunity to obtain critical information on which to 

evaluate the adequacy of the standards. While the surveys of the Hartford 

and Nashville facilities conducted shortly before the fires found that the 

facilities met all applicable federal standards, many other unsprinklered 

nursing homes are not required to meet all standards if they obtain a 

waiver from CMS or demonstrate a level of fire protection equivalent to 

the standards. However, we found that the exemption of some 

unsprinklered facilities from certain standards may jeopardize resident 

safety. For example, unsprinklered facilities in some states have received 

CMS waivers of certain ventilation system requirements for preventing the 

spread of smoke, yet fire safety experts consider such waivers to present 

an unacceptable hazard. Furthermore, while facilities that demonstrate 

equivalency are not required to meet all federal standards, in some cases 

facilities are exempt from important standards, such as that the fire alarm 

be either monitored or linked directly to the local fire department. We also 

identified assessments of equivalency in unsprinklered facilities that were 

not evaluated correctly or not updated as facility conditions changed, 

placing residents at unnecessary risk. 
Page 5 GAO-04-660 Nursing Home Fire Safety 

State and federal oversight of nursing home compliance with fire safety 

standards is inadequate. Postfire investigations by Connecticut and 

Tennessee revealed deficiencies that existed, but were not cited, during 

prior surveys. The Hartford facility was surveyed less than 1 month before 

the fire, and no violations of federal standards were identified. However, 

the survey agency’s postfire investigation found that the home was not 

conducting required fire drills during the night shift, and that on the night 

of the fire the staff failed to follow the facility’s fire plan. The agency did 

not interview night shift staff during its prefire survey and was provided 

inaccurate documentation of fire drills by the nursing home. During 

routine fire safety surveys, Tennessee surveyors repeatedly failed to detect 

a deficiency that would allow smoke to travel between floors—a problem 

that may have contributed to the spread of smoke to upper floors where 

one-third of residents who died succumbed to smoke inhalation. 

Tennessee’s postfire investigation did not cite the home for any 

deficiencies and did not pursue potential deficiencies that may have been 

present at the time of the fire. For example, surveyors did not determine if 

the nursing home staff appropriately implemented the home’s fire plan 

during the fire, even though the home had been cited repeatedly for this 

deficiency on prior surveys. The results of CMS’s federal fire safety 

monitoring surveys conducted during fiscal year 2003 found that state 

surveyors either missed or failed to cite an average of more than two 

deficiencies per home surveyed, such as inadequate construction to 

contain fire and smoke or missing or improperly maintained sprinkler 

systems. CMS provides insufficient oversight of state survey activities to 

address these and other fire safety concerns. CMS did not fully comply 

with the statutory requirement to conduct federal monitoring surveys in at 

least 5 percent of surveyed nursing homes in each state—a total of over 

800 federal surveys annually; only 40 federal surveys conducted in fiscal 

year 2003 covered fire safety, a required element of both state and federal 

surveys. No federal assessments of fire safety were conducted in 27 states. 

Four of CMS’s 10 regions did not require states to request waiver renewals 

or states in those regions did not submit waiver renewals, and 8 of 10 

regional offices did not routinely review the accuracy of fire safety 

equivalency assessments, as CMS requires. Furthermore, CMS lacks data 

to identify the extent to which facilities have sprinklers, data that would 

be useful in reviewing the appropriateness of waivers or equivalency 

assessments. 

We are making several recommendations to the Administrator of CMS to 

(1) improve oversight of federal fire safety standards, such as ensuring 

that the fire safety component is included in federal monitoring surveys 

and reviewing the appropriateness of exemptions to federal standards 
Page 6 GAO-04-660 Nursing Home Fire Safety 

granted to unsprinklered facilities and (2) strengthen fire safety standards 

by working with NFPA to reexamine standards for unsprinklered homes 

and by ensuring thorough investigations of multiple-death nursing home 

fires in order to reevaluate the adequacy of fire safety standards. In 

commenting on a draft of this report, CMS concurred with our 

recommendations and provided examples of steps it is already taking to 

implement those recommendations. We also provided a draft of this report 

to the Connecticut and Tennessee state survey agencies and NFPA for 

comments. CMS, Connecticut, and NFPA provided technical and clarifying 

comments, which we incorporated as appropriate. Tennessee did not 

provide comments. 

Combined Medicare and Medicaid payments to nursing homes for care 

provided to vulnerable elderly and disabled beneficiaries totaled about 

$64 billion in 2002, with a federal share of approximately $45.5 billion. 

Oversight of nursing home fire safety is a shared federal-state 

responsibility. Based on statutory requirements, CMS defines standards 

that nursing homes must meet to participate in the Medicare and Medicaid 

programs and contracts with states to assess whether homes meet these 

standards through annual surveys and complaint investigations. CMS is 

also responsible for monitoring the adequacy of state survey activities. 

Under federal law, CMS does not develop fire safety standards itself but 

instead adopts standards developed through a consensus process by 

NFPA, of which CMS is a member. NFPA generally updates the standards 

every 3 years, but CMS has updated federal standards less frequently. The 

NFPA standards were first applied by CMS to health care facilities such as 

hospitals and nursing homes in 1971 when CMS adopted the 1967 NFPA 

code. The federal standards for nursing homes were subsequently updated 

when CMS adopted the 1973, 1981, 1985, and 2000 editions of the NFPA 

code.5

 The agency has the authority to modify or make exceptions to the 

 5

CMS proposed updating federal fire safety standards in 1990, but no changes were adopted 

because of the estimated cost of implementing some of the new requirements. 

Background 

Fire Safety Standards 
Page 7 GAO-04-660 Nursing Home Fire Safety 

NFPA standards but has rarely done so.6 States are free to adopt and apply 

stricter standards under their state licensure authority. 

Nursing home fire safety standards are built on several principles that 

combine certain construction and operational features along with an 

acceptable staff response. These principles are a reflection of the mobility 

and cognitive limitations of many elderly and disabled residents who 

cannot be easily evacuated in the event of a fire. The principles include 

(1) appropriate design and construction of the facility, particularly 

compartmentation to contain both fire and smoke; (2) provision for fire 

detection, alarm, and extinguishment, such as smoke detectors and 

sprinkler systems; and (3) fire prevention policies and the testing of plans 

for staff response, such as steps to isolate the fire and transfer occupants 

to areas of refuge. 

The fire safety standards for nursing homes cover 18 categories ranging 

from building construction to furnishings. Examples of specific 

requirements include (1) the use of fire or smoke resistant construction 

materials for interior walls and doors; (2) installation and testing of fire 

alarms and smoke detectors; (3) protection of hazardous areas, such as 

laundry rooms; (4) regulation of smoking by residents; and (5) 

development and routine testing of a fire emergency plan. The standards 

differentiate between “existing” and “new” facilities. In the past, whenever 

a new edition of the NFPA code was adopted by CMS, nursing homes had 

the option of complying with the new standards or with an earlier edition 

of the standards. Thus, a nursing home that began serving Medicare and 

Medicaid residents under the 1967 edition of the standards could have 

continued to be surveyed under those standards up until 2003. With the 

implementation of the 2000 edition of the NFPA standards in 2003, 

however, CMS eliminated the option for facilities to be “grandfathered” 

under earlier editions. All nursing homes participating in Medicare and 

Medicaid as of March 2003 must comply with the 2000 standards for 

existing facilities. 

 6

Under federal law, CMS is generally required to specify in regulation which provisions of 

the NFPA fire safety code are applicable to nursing homes. See 42 U.S.C. § 1395i-3(d)(2)(B) 

(2000). Until 2003, CMS adopted the NFPA standards without any changes. In adopting 

NFPA’s 2000 code, however, CMS modified the application of the code’s roller latch 

requirement in unsprinklered buildings and strengthened requirements for emergency 

lighting. 
Page 8 GAO-04-660 Nursing Home Fire Safety 

Every nursing home receiving Medicare or Medicaid payment must 

undergo a standard survey not less than once every 15 months, and the 

statewide average interval for these surveys must not exceed 12 months.7

A standard survey is conducted by state survey agency personnel and 

entails an assessment of both federal quality of care and fire safety 

requirements.8

 Most states use fire safety specialists within the same 

department as the state survey agency to conduct fire safety inspections, 

but 16 states contract with their state fire marshal’s offices. The fire safety 

portion of a standard survey is not always conducted concurrently with 

the quality of care review, particularly in states that contract with the state 

fire marshal. All personnel conducting the inspections are required to 

complete a self-paced, computer-based course before registering for and 

completing 5 days of classroom training on fire safety standards. 

Fire safety inspections focus on the home’s compliance with federal 

requirements for health care facilities. When a deficiency is found, it is 

assigned to 1 of 12 categories according to its scope (the number of 

residents potentially or actually affected) and its severity. An A-level 

deficiency is the least serious and is isolated in scope, while an L-level 

deficiency is the most serious and is considered to be a widespread 

problem involving immediate jeopardy (see table 1).9

 States are required to 

enter information about surveys and complaint investigations, including 

the scope and severity of deficiencies identified, in CMS’s OSCAR 

database. 

 7

See 42 U.S.C. § 1395i-3(g)(2) and 42 U.S.C. § 1396r(g)(2). Among other things, these 

statutory provisions require standard surveys to include assessments of the physical 

environment, which is defined by CMS to include fire safety standards. See 42 C.F.R. § 

483.70(a) (2003). 

8

See 42 C.F.R. § 488.110. CMS guidance also contains a specific reference to the fire safety 

component of a standard survey. 

9

Most fire safety deficiencies identified during routine inspections are cited at less than 

actual harm because actual harm is reserved for fire-related injuries. Nationwide, only 43 

deficiencies on current fire safety surveys as of December 1, 2003, were cited at the actual 

harm or higher level. A somewhat higher proportion of deficiencies were cited at the D–F 

level (57 percent) than at the A–C level (43 percent). 

State Oversight of Fire 

Safety 
Page 9 GAO-04-660 Nursing Home Fire Safety 

Table 1: Scope and Severity of Deficiencies Identified during Nursing Home 

Surveys 

 Scopea

Severity Isolated Pattern Widespread

Immediate jeopardyb J K L 

Actual harm G H I 

Potential for more than minimal harm D E F 

Potential for minimal harmc A B C 

Source: CMS. 

a

CMS defines the scope levels as follows: isolated—affecting a single or a very limited number of 

residents; pattern—affecting more than a very limited number of residents; and widespread—affecting 

or having the potential to affect a large portion of or all residents. 

b

Actual or potential for death/serious injury. 

c

Nursing home is considered to be in “substantial compliance.” 

If a deficiency is cited, a nursing home may have three alternatives (see 

fig. 1). First, a home may be required to prepare a plan of correction that 

eliminates an identified fire safety deficiency, a fact that may be verified 

on a subsequent revisit. Second, a home may request a waiver from 

compliance with the requirement through the state survey agency if the 

cost of correcting the deficiency would place a financial or other undue 

hardship on the facility and the health and safety of the residents would 

not be at risk if the deficiency remains uncorrected. In general, waivers are 

limited to deficiencies cited at less than actual harm. Waivers must be 

reviewed and approved by one of CMS’s regional offices. Waivers may be 

temporary—to allow a home to develop and obtain approval of a 

construction plan—or longer term in nature. 

Third, as an alternative to correcting or receiving a waiver for deficiencies 

identified on a standard survey, a home may undergo an assessment using 

the Fire Safety Evaluation System (FSES). FSES was developed by the 

Department of Commerce’s National Institute of Standards and 

Technology to provide a means for providers who participate in the 

Medicare and Medicaid programs to meet the fire safety objectives of the 

standards without necessarily being in full compliance with every 

standard.10 FSES uses a grading system to compare the overall level of fire 

safety in a specific facility to a hypothetical facility that exactly matches 

 10The institute was formerly known as the National Bureau of Standards. 
Page 10 GAO-04-660 Nursing Home Fire Safety 

each requirement of the fire safety standards.11 FSES may be conducted by 

either the state or the facility, but CMS requires both the state survey 

agency and the regional office to review the results. Once a facility has 

been certified using FSES, it can continue to be certified on that basis in 

subsequent years provided there are no significant changes that might 

alter the FSES score. However, an annual survey must still be conducted. 

Figure 1: How Nursing Homes May Address Fire Safety Deficiencies 

CMS is responsible for assessing the adequacy of state survey activities to 

ensure nursing home compliance with federal fire safety requirements. To 

assess the adequacy of state surveys, CMS is required by statute to 

conduct federal monitoring surveys annually in at least 5 percent of the 

Medicare and Medicaid nursing homes surveyed by each state with a 

minimum of five facilities per state.12 The federal monitoring surveys are 

required to include an assessment of the fire safety component of states’ 

 11Point values are assigned to various fire safety features, such as sprinklers, smoke 

detectors, construction types, and corridor doors. A facility passes FSES if its point score 

meets or exceeds that of the hypothetical facility. 

12See 42 U.S.C. § 1395i-3(g)(3) and 42 U.S.C. § 1396r(g)(3). 

Federal Oversight of State 

Survey Agencies 

Waiver

Source: GAO analysis of CMS guidance.

Federal standards

Standards 

met

Certified to participate

Some standards 

not met

Deficiency

correction

required 

Fire Safety

Evaluation System

State

survey
Page 11 GAO-04-660 Nursing Home Fire Safety 

standard surveys.13 Federal monitoring surveys can be either comparative 

or observational. Comparative surveys involve a federal survey team 

conducting a complete, independent survey of a home within 2 months of 

the completion of the state’s survey in order to compare and contrast the 

findings. In an observational survey, one or more federal surveyors 

accompany a state survey team to a nursing home to observe the team’s 

performance. CMS also analyzes the results of state surveys to identify 

trends or anomalies, such as a failure to cite certain types of deficiencies 

or citation of deficiencies at an inappropriate scope and severity level. As 

noted earlier, regional office staff are required to review and approve state 

requests to waive fire safety standards and to review the results of FSES 

assessments. 

Table 2 provides key facts about the circumstances of the 2003 Hartford 

and Nashville fires in which 31 residents lost their lives. As with earlier 

multiple-death fires (1) the homes were constructed of noncombustible 

materials and therefore were not required to be sprinklered; (2) the fires 

occurred at night, when staffing is at the lowest level; and (3) each fire 

broke out in a resident’s room. The cause of the fire in Nashville remains 

undetermined, while the Hartford investigations concluded that a 23-yearold cognitively impaired resident set the fire.14 As shown in table 2, both 

nursing homes had undergone their annual safety survey within 1 to 

4 months of the fires. Most of the deaths in the Hartford and Nashville fires 

were due to smoke inhalation rather than burns. According to CMS 

officials, state survey agencies are required to treat a fire-related death in a 

nursing home as a complaint and must conduct a complaint investigation. 

 13The monitoring surveys must be sufficient in number to allow inferences about the 

adequacy of the states’ surveys. CMS is required to conduct monitoring surveys using the 

same protocols as states are required to use in their surveys. In addition, CMS may 

determine that a nursing home does not meet applicable requirements, including fire safety 

requirements. 

14Various authorities, including the state fire marshal’s office, the local fire departments, 

and the state survey agencies, conducted investigations of these two nursing home fires. 

Hartford and Nashville 

Nursing Home Fires 
Page 12 GAO-04-660 Nursing Home Fire Safety 

In the case of a multiple-death fire, CMS staff from a regional office or 

from central office may also be involved in the investigation.15

Table 2: Key Facts about the Hartford and Nashville Nursing Home Fires 

Key facts Hartford Nashville 

Date and time of fire February 26, 2003; alarm 

received by fire department 

at 2:38 a.m. 

September 25, 2003; alarm 

received by fire department 

at 10:18 p.m. 

Date of last fire safety 

inspection 

January 29, 2003 May 27, 2003 

Number of residents 148 118 

Fire department response 6 minutes after notification 9 minutes after notification 

Origin of fire Resident’s room Resident’s room 

Nursing home staff on duty 12 12 

Construction type Noncombustible with 1-hour 

fire-rated exterior walls and 

structural frame. 

Unsprinklered. 

Noncombustible with 

2-hour fire-rated exterior 

walls and structural frame. 

Unsprinklered. 

Year(s) of construction 1970 and 1974 1967 

Number of floors in facility 1 4 

Number of deaths 16, primarily in vicinity of 

room where fire broke out. 

15; 10 residents died on 

2nd floor where fire 

originated. Five residents 

died on 3rd and 4th floors. 

Cause of fire Arson by cognitively 

impaired resident with a 

history of self-inflicted 

cigarette burns. 

Undetermined. 

Sources: Hartford and Nashville Fire Departments and Connecticut and Tennessee State Fire Marshals. 

 15On March 11, 2004, CMS issued new guidance outlining procedures to be followed by 

state survey agencies, CMS regional offices, and the CMS central office in the event of a fire 

resulting in serious injury or death in a Medicare- or Medicaid-certified health facility. The 

guidance directs the state survey agency to inform the CMS regional office and to conduct 

an on-site fire safety survey of the facility as part of its investigation. Regional office and 

central office staff are available to consult and may, at their discretion, accompany state 

survey agency staff during their on-site survey. The CMS central office is directed to 

consult with the regional office following the state survey agency investigation to 

determine if further investigation is warranted concerning the adequacy and application of 

current standards. 
Page 13 GAO-04-660 Nursing Home Fire Safety 

Although there has never been a multiple-death fire in a fully sprinklered 

nursing home, cost has been an impediment to requiring all homes to 

install automatic sprinklers. Newly constructed homes must incorporate 

sprinkler systems; however, older homes that meet certain construction 

standards are not required to install sprinklers in part because of the cost 

of retrofitting such structures. The decline in multiple-death fires with the 

introduction and enforcement of fire safety standards was also a rationale 

for not requiring sprinklers for older structures. The Hartford and 

Nashville fires, however, have reopened the debate about the need to 

retrofit older nursing homes. 

As the fire safety code evolved over time, a properly functioning, 

automatic sprinkler system came to be regarded as the single most 

effective fire protection feature. From 1994 through 1998, NFPA data show 

an 82 percent reduction in the chances of death occurring in a sprinklered 

nursing home: 1.9 deaths per 1,000 fires in sprinklered facilities versus 

10.8 deaths per 1,000 fires in unsprinklered homes. In general, if a facility 

is fully sprinklered, the standards allow a less stringent set of requirements 

to apply for building construction, smoke and fire containment, and 

protection of hazardous areas. In 1991, the NFPA code began requiring full 

sprinkler coverage for newly constructed nursing homes or for any portion 

of a home that underwent a substantial renovation. CMS adopted this 

requirement for new construction when it began using the 2000 edition of 

the NFPA fire safety code in 2003. Although CMS has the authority to 

require sprinklers for any facility that serves Medicare and Medicaid 

beneficiaries, it generally follows the NFPA fire safety code. 

CMS does not require certain older nursing homes of noncombustible 

construction to install sprinklers (see table 3). While combustible facilities 

are typically built of wood, the materials used in noncombustible nursing 

homes include concrete, steel, or brick. Whether a noncombustible 

nursing home requires sprinklers depends on a combination of factors: 

(1) the ability of exterior walls, the structural frame, and flooring to resist 

fire, known as fire resistance rating, and (2) the number of floors. A facility 

is referred to as “protected” if the construction materials are rated to 

withstand a fire for a minimum of 1 hour, while a home with less than 

1-hour fire-rated construction is considered to be “unprotected.” For 

example, a noncombustible nursing home with one story and a fire 

resistance rating of 1 hour, such as the Hartford facility, need not be 

sprinklered. Because of the difficulty of evacuating nursing home 

residents, a comparable structure that is more than one story requires 

sprinklers. The four-story Nashville facility, however, had 2-hour fire-rated 

walls and flooring and thus did not require sprinklers. 

Despite Effectiveness, 

Cost Has Been a 

Barrier to Requiring 

Sprinklers for All 

Older Nursing Homes 
Page 14 GAO-04-660 Nursing Home Fire Safety 

Table 3: Sprinkler Requirements for Existing Nursing Homes, by Construction Type 

Construction type 

Fire resistance rating of 

exterior walls, the 

structural frame, and 

flooring (in hours)

Number of 

floors

(maximum)

Sprinklers required 

Noncombustible 0-1 2-3

Mixed combustible/noncombustible 2 1-2

Combustible (heavy timber) 2a2

Combustible 0-1 1-2

Sprinklers not required 

Noncombustible 2-4bNo limit

Noncombustible 1 1

Sources: CMS and NFPA. 

Note: These requirements are based on the current federal fire safety standards that were updated in 

2003. 

a

The 2-hour fire resistance rating applies to exterior walls only. Heavy timber is permitted for the 

construction of the structural frame and flooring. 

b

For buildings with 3 to 4 hour fire-rated walls, the fire resistance rating for flooring is 2 to 3 hours. 

NFPA considered requiring sprinklers for all existing nursing homes on 

several occasions in the past. Improvements in the fire safety record of 

nursing homes, however, suggested that such a requirement was not cost 

effective. When the federal government first adopted the NFPA fire safety 

standards in 1971, the number of multiple-death fires in nursing homes 

was about 15 to 18 per year. With the adoption and enforcement of these 

standards, including the requirement for sprinklers in homes that were not 

highly fire resistant, the number of fire-related nursing home fatalities 

dropped dramatically. Though infrequent, multiple-death nursing home 

fires have led some states to require nursing homes to be retrofitted with 

sprinklers, such as Virginia after 12 residents died in a 1989 fire.16 From 

 16States can enforce such requirements because facilities must obtain a state license in 

order to operate. During the course of our work, we contacted state survey agencies and 

fire marshals in several states that were reported to have required existing nursing homes 

to install sprinklers. We were able to confirm that the following states had required homes 

to be retrofitted with sprinklers: Ohio, Utah, Virginia, Vermont, and West Virginia. In 

addition, a 1990 New Jersey statute required many, but not all, existing homes to install 

sprinklers. 
Page 15 GAO-04-660 Nursing Home Fire Safety 

1990 through 2002, there were no major nursing home fires with such a 

high number of fatalities.17

The Hartford and Nashville fires reopened the issue of requiring the 

retrofitting of existing nursing homes with sprinklers. In the aftermath of 

these fires, both Connecticut and Tennessee passed laws requiring all 

nursing homes to install sprinkler systems.18 In addition, the International 

Fire Marshals’ Association proposed amending the 2003 NFPA code on an 

emergency basis. According to an NFPA official, this proposal was not 

adopted because committee members had not seen the results of the 

Hartford and Nashville fire investigations and because it lacked a 

transition period for homes to come into compliance. However, the NFPA 

technical committee responsible for health care facilities voted in 

February 2004 to revise the code to require existing homes to be 

retrofitted with sprinklers.19 If the technical committee’s recommendation 

is upheld, the change would be effective with the 2006 NFPA code update, 

but would not be incorporated into federal nursing home fire safety 

standards until formally adopted by CMS.20 The American Health Care 

Association (AHCA), the association representing primarily for-profit 

nursing homes, has also endorsed requiring all homes to be sprinklered. 

AHCA, however, believes that there must be (1) some discussion about 

how to pay for sprinklers and (2) a transition period of from 3 years to 

5 years for homes to come into compliance.21

 17In Arkansas and Mississippi, nursing home fires in 1990 and 1995, respectively, resulted in 

the deaths of three residents in each facility. 

18To determine the sprinkler status of facilities, Connecticut state survey officials relied on 

data collected during prior surveys and, if there was a question, sent a surveyor out to the 

home. Of Connecticut’s 254 nursing homes, 206 are fully sprinklered, 31 are partially 

sprinklered, and 17 have no sprinklers. In contrast, state survey officials in Tennessee 

visited each nursing home. Of Tennessee’s 343 nursing homes, 229 are fully sprinklered, 90 

are partially sprinklered, and 24 have no sprinklers. 

19In the NFPA code development process, the proposal will be reviewed again in November 

2004 and presented to the NFPA membership in June 2005. 

20To update federal fire safety standards, CMS must publish and solicit comments on the 

proposed new standards in the Federal Register. After reviewing public comments, CMS 

publishes a final version of its standards with an effective date. The process of adopting 

NFPA’s 2000 standards in 2003 took CMS about 16 months. 

21Although it may vary from state to state, a portion of the cost of installing sprinklers, 

equal to a home’s percentage of Medicaid beneficiaries, may be eligible for reimbursement 

as a capital improvement under the Medicaid program. 
Page 16 GAO-04-660 Nursing Home Fire Safety 

Although concerns about cost have been a barrier to requiring all homes to 

install sprinklers, CMS has not developed its own cost estimate for 

retrofitting older nursing homes. An October 2003 estimate developed for 

AHCA by a fire-safety consulting firm suggested that the cost of installing 

sprinklers in all nursing homes would be about $1 billion. However, there 

is considerable uncertainty about the assumptions on which the estimate 

is based. For example, the estimate assumed that about 25 percent of 

nursing homes are unsprinklered, treating partially sprinklered facilities as 

unsprinklered. We found that the term “partially sprinklered” covers 

homes that have very few sprinklers as well as homes that are almost 

completely sprinklered.22 Furthermore, CMS as well as states lack 

complete and reliable data on the extent to which homes are partially 

sprinklered.23 Other uncertainties in the AHCA cost estimate involve the 

square footage requiring sprinkler coverage and the cost per square foot. 

AHCA assumed that the average unsprinklered home is 40,000 square feet 

and that the cost of retrofitting sprinklers in such homes was 

approximately $7 per square foot. A 2004 survey by the Tennessee state 

survey agency found that the average unsprinklered square footage of 

state nursing homes was about half that of the AHCA estimate. In addition, 

the $7 per square foot estimate could be higher or lower depending on 

circumstances, such as whether asbestos abatement is required or 

whether a home has to install storage tanks or pumps to compensate for 

inadequate municipal water supplies. Moreover, a Connecticut state 

survey agency official identified other costs that may be associated with 

sprinkler installation, such as potential lost revenue if admissions need to 

be suspended or residents need to be moved to a different facility during 

the construction. 

 22For example, a partially sprinklered home could have sprinklers in hazardous areas only 

(laundry rooms and storage areas), lack sprinklers only in areas such as attics or closets in 

residents’ rooms, or have sprinklers in only one wing of a multiwing facility. 

23Neither of the informal CMS or AHCA surveys conducted after the 2003 fires asked for 

data on partially sprinklered homes. CMS asked for the number of sprinklered and 

unsprinklered homes in each state, while the AHCA survey of its state affiliates requested 

data on the proportion of homes fully sprinklered. CMS obtained information for 30 states, 

and 33 state affiliates responded to the AHCA survey. Since AHCA represents primarily 

for-profit nursing homes, its state affiliates’ survey excludes many not-for-profit nursing 

homes. 
Page 17 GAO-04-660 Nursing Home Fire Safety 

The nursing home fires in Hartford and Nashville during 2003 as well as 

our review of waivers and FSES results revealed weaknesses in federal 

fire safety standards and their application to unsprinklered nursing homes. 

Neither home was required to have automatic sprinklers because of their 

noncombustible type of construction. Federal standards, however, 

allowed these homes to operate without several basic fire safety features, 

such as smoke detectors in resident rooms that could have helped to 

compensate for the lack of sprinklers. While the surveys of the Hartford 

and Nashville facilities conducted shortly before the fires either found 

compliance with federal standards or required corrective action, many 

other unsprinklered homes, including some constructed of combustible 

materials, are not required to meet all federal standards if they obtain a 

waiver from CMS or demonstrate an equivalent level of fire protection 

using FSES. Our review of selected waivers and FSES results, however, 

found that resident safety was sometimes jeopardized by inappropriate 

use of these alternatives to actual compliance. 

State and local fire investigators looking into the causes and origins of the 

Hartford and Nashville fires identified a variety of factors that may have 

contributed to the substantial loss of life, including some that reflect 

potential weaknesses in federal fire safety standards (see table 4). Because 

both nursing homes were constructed of noncombustible material with the 

minimum fire ratings required by their height (number of floors), neither 

was required to have automatic sprinklers in order to meet federal fire 

safety standards. In the absence of sprinklers, however, they were highly 

dependent on a variety of other building features and systems, as well as 

staff response, for fire detection and containment. Contrary to actions 

taken in previous multiple-death nursing home fires, neither CMS nor 

NFPA investigated the Hartford or Nashville fires to assess the adequacy 

of the current fire safety standards.24 Consequently, they lack the firsthand 

information needed to determine the degree to which the multiple-deaths 

were due to weaknesses in federal fire safety standards and to make 

recommendations for future revisions to the standards. 

 24NFPA was on-site following the Harford fire but did not conduct a full investigation or 

publish its own investigation report. Although the Connecticut and Tennessee state survey 

agencies each conducted complaint investigations after the fires in their respective states, 

the objective of such complaint surveys is to determine whether the homes had failed to 

comply with any federal fire safety standards, not to assess the adequacy of the standards. 

Federal Fire Safety 

Requirements for 

Unsprinklered 

Nursing Homes Are 

Weak 

2003 Fires Revealed 

Weaknesses in Federal 

Nursing Home Fire Safety 

Standards 
Page 18 GAO-04-660 Nursing Home Fire Safety 

Table 4: Potential Weaknesses in Federal Standards Contributing to Multiple Deaths in Hartford and Nashville Nursing Home 

Fires 

 Potential weaknesses 

Federal standard Hartford nursing home Nashville nursing home 

Smoke detectors Depending on date of 

construction, smoke detectors 

may be required in corridors or 

resident rooms.a

Smoke detectors not required. 

No smoke detectors in resident 

rooms. 

Smoke detectors not required. 

No smoke detectors in resident 

rooms. 

Fire and smoke barriers Complete fire and smoke 

barriers required between 

corridor and resident rooms; not 

required between resident 

rooms. 

Residents in room adjacent to 

room of origin died from smoke 

inhalation. Smoke and fire 

spread through space above 

false ceiling. 

Residents in room adjacent to 

room of origin died from smoke 

inhalation. Investigative reports 

do not indicate if fire spread 

through space above false 

ceilings. 

Heating, ventilating, and airconditioning (HVAC) system Depending on date of 

construction, dampers may be 

required in ductwork to prevent 

the spread of fire and smoke. 

Not applicable.b Under the 1967 standards, the 

home was not required to have 

dampers in ductwork. Ductwork 

did not have dampers, allowing 

smoke to spread to upper 

floors of building. 

Staff response The staff is expected to 

implement the written plan for 

the protection of all residents, 

such as taking steps to contain 

the fire and evacuate residents. 

Staff may have failed to close all 

resident room doors, and all 

designated staff did not respond 

to assist in containment and 

evacuation of residents as 

called for in fire plan. 

Not clear from available 

investigations. 

Sources: GAO analysis of information provided by state and local fire investigations in Hartford and Nashville, and by CMS and NFPA. 

a

Although both homes had corridor smoke detectors, they were not required. The requirement for 

smoke detectors in either corridors or resident rooms was added to federal standards in 1981 and 

only for new facilities constructed after that date. Older, existing facilities, such as the Hartford and 

Nashville nursing homes, were exempt from this requirement. 

b

The facility did not have a central heating and cooling system with ductwork but rather relied on wallmounted heat pumps in each resident’s room. 

The fire safety standards applicable to these two nursing homes did not 

require smoke detectors in resident rooms and neither home had them. 

Although federal standards for most nursing homes do not require smoke 

detectors, the two facilities did have smoke detectors in the corridors. 

Only nursing homes surveyed under federal standards for new 

construction since 1981 were required to have either corridor or in-room 

smoke detectors. According to fire department investigators and state 

officials, the lack of smoke detectors in resident rooms may have 

contributed to a delay in both staff response and fire department 

notification; earlier detection of these fires may have helped to limit the 
Page 19 GAO-04-660 Nursing Home Fire Safety 

number of fatalities.25 In the Nashville fire, the fire alarm was activated by 

corridor smoke detectors. The Tennessee fire marshal’s office concluded 

that there was evidence of heavy smoke production in the room where the 

fire originated prior to discovery of the fire. The fire marshal’s report 

indicated that a large gap between the top of the doorway and the ceiling 

created a large airspace that delayed smoke from entering the hallway and 

activating the smoke alarm until the space was filled to capacity. In the 

Hartford fire, it is unclear whether the alarm was first activated by the 

corridor smoke detector or manually by the staff member who first 

attempted to extinguish the fire. According to the Hartford fire 

department, the absence of smoke detectors in resident rooms contributed 

to a delay of up to 5 minutes or more. However, an NFPA official 

questioned the basis for this estimate given the lack of a detailed timeline 

of the events prior to activation of the home’s fire alarm. In recognition of 

the importance of smoke detectors, Tennessee is now requiring all newly 

licensed nursing homes to have smoke detectors in resident rooms and the 

Hartford facility is voluntarily installing smoke detectors in all resident 

rooms.26

Another potential weakness in federal standards, particularly in an 

unsprinklered facility, is that resident rooms are not required to be 

separated from each other by fire or smoke barriers. According to 

Connecticut survey agency officials, the open doors rather than the lack of 

a complete smoke barrier was the primary factor contributing to the 

spread of smoke. Investigative reports from the Hartford fire indicated 

that fire and smoke also spread from the room of origin to the adjacent 

room through the space above the false ceiling. However, even if all doors 

had been closed, as called for in the nursing home’s fire plan, smoke could 

still have spread to the adjacent room through space above the false 

ceiling. In addition, the 1967 standards applied to the Nashville facility did 

not require smoke dampers in the ventilation ductwork to prevent the 

 25In contrast, the presence of smoke detectors in resident rooms made a significant 

difference in a December 2003 nursing home fire in Nevada. A resident smoking in bed 

while on oxygen started a fire at 2:20 a.m. Staff were alerted by the in-room smoke 

detector, and the fire was extinguished before it caused a significant amount of damage. 

While the resident who started the fire subsequently died as a result of the fire, no other 

deaths were reported. Although the facility was equipped with automatic sprinklers, the 

buildup of heat from the fire had not reached a level sufficient to activate the sprinklers. 

26Although it was not enacted, the bill originally required all unsprinklered nursing homes 

to install smoke detectors in resident rooms if a sprinkler system had not been installed 

within 1 year of the legislation’s effective date. 
Page 20 GAO-04-660 Nursing Home Fire Safety 

spread of smoke, although subsequent editions of the standards do require 

such dampers.27

According to NFPA officials, the fire safety standards’ heavy reliance on 

appropriate staff response in a nursing home fire may not always be 

realistic, suggesting the need to reevaluate the policy of allowing some 

nursing homes to operate without automatic sprinkler systems.28 The 

multiple deaths in these fires resulted most directly from a failure to 

contain the spread of smoke. The primary factor contributing to the 

spread of smoke in the Hartford fire was human error. Staff may have 

failed to follow the facility fire plan and close all resident room doors and 

all designated staff did not respond with fire extinguishers as called for in 

the fire plan. 

CMS’s 2003 adoption of the 2000 NFPA standards is likely to have little 

effect on fire detection or containment in existing nursing homes, such as 

those in Hartford and Nashville. Only one of the potential weaknesses 

discussed above is addressed by the new standards. Smoke dampers will 

now be required where ductwork passes through a smoke barrier, and 

older homes, such as the Nashville facility, will no longer be 

“grandfathered” under earlier editions of the standards that do not include 

such a requirement. However, a facility that lacks dampers in ductwork as 

required by current federal standards could still be certified for Medicare 

or Medicaid by obtaining a waiver of this requirement from CMS. The new 

standards make no change to requirements for existing facilities regarding 

smoke detectors or separation of resident rooms. However, CMS guidance 

still requires smoke detectors in resident rooms and fire-rated separation 

of resident rooms as compensating features when considering waivers for 

some unsprinklered one-story, wood-frame facilities. 

In past cases of multiple-death nursing home fires, both CMS and NFPA 

have conducted their own investigations and issued reports on the fires, in 

addition to investigations conducted by state and local authorities into fire 

cause and origin and by state survey agencies that examine a facility’s 

 27Because the facility was originally certified when the 1967 federal fire safety standards 

were in effect, it was grandfathered and continued to be surveyed under the 1967 

standards. 

28Even though the fire safety standards call for closing all doors in the event of a fire, an 

NFPA official acknowledged it can be difficult for staff to abandon a resident who cannot 

be evacuated from the room of fire origin in order to focus on the safety of other residents. 
Page 21 GAO-04-660 Nursing Home Fire Safety 

compliance with current fire safety standards.29 According to a CMS 

official, fires are a test of the standards designed to safeguard life and 

property, providing an opportunity to identify strengths and weaknesses. 

The purpose of such a postfire review is to determine whether 

modifications to the standards or their implementation are needed to 

prevent similar occurrences in the future. The findings of such reviews can 

then be taken into consideration by NFPA as part of its code revision 

process. In the case of the Hartford and Nashville fires, however, no such 

reviews were conducted.30 An NFPA official told us that the Nashville fire 

authorities turned down NFPA’s request to investigate the fire. In the 

absence of such reviews, both CMS and NFPA lack access to critical 

firsthand information on which to judge the need for revisions to federal 

fire safety standards. 

Our review of waiver and FSES results found that resident safety may be 

compromised in some unsprinklered nursing homes that were granted 

exceptions to federal fire safety standards.31 While the Hartford and 

Nashville facilities were determined to have met all federal standards prior 

to the fires, many other unsprinklered nursing homes are exempt from 

meeting certain provisions of the standards if they obtain a waiver from 

CMS or demonstrate an equivalent level of fire protection using FSES. 

Waivers and FSES allow homes to avoid costly renovations, but homes are 

required to demonstrate that resident safety would not be compromised. 

Approximately one in five nursing homes nationwide (1) receives a waiver 

of one or more fire safety standards, (2) obtains a passing score on FSES, 

or (3) uses a combination of waivers and FSES. 

 29Multiple-death nursing home fires investigated by CMS, NFPA, or both included fires in 

Ocean Springs, Mississippi (1995); Dardanelle, Arkansas (1990); Norfolk, Virginia (1989); 

Memphis, Tennessee (1988); and Little Rock, Arkansas (1984). 

30An NFPA official told us that the organization did work on-site with Hartford authorities 

but did not conduct a full investigation or issue a report. However, NFPA did publish an 

article on the fire in the May/June 2003 Fire Journal. 

31We focused on examining waivers and FSES results in four states reported by CMS to 

have high proportions of unsprinklered nursing homes: Arkansas, Iowa, Pennsylvania, and 

Wisconsin. We examined waiver and FSES documentation for selected facilities that were 

not fully sprinklered and had deficiencies that could contribute to the spread of smoke, the 

factor that led to most of the deaths in the Hartford and Nashville nursing home fires. 

Exemptions from Federal 

Fire Safety Standards Are 

a Concern in Some 

Unsprinklered Nursing 

Homes 
Page 22 GAO-04-660 Nursing Home Fire Safety 

Some waivers of federal fire safety standards, or combinations of waivers, 

pose a significant risk to resident safety in some unsprinklered facilities. In 

our view, CMS’s ability to exempt facilities from selected standards 

through waivers is equivalent to exercising a standard-setting role.32 In 

some cases, waivers of sprinkler requirements were granted for many 

years even though the facilities lacked adequate compensating fire 

detection and containment features. As of December 2003, 15 percent of 

nursing homes in 30 states operated with waivers of certain federal fire 

standards. However, the proportion of homes that have applied for and 

received waivers varies widely, from less than 1 percent of homes in 

California, Florida, and Maine to more than 57 percent in Ohio as of 2003. 

The most frequently waived requirement that may pose a risk to residents 

is that the HVAC system meets applicable codes and is constructed to 

restrict the spread of smoke and fire within the building. As of December 

2003, 10 percent of all nursing homes nationwide (1,556 of 16,334) were 

cited for deficiencies in this area on their most recent surveys; half of 

these subsequently received waivers of this standard and were not 

required to make corrections. In Arkansas, however, 26 percent of nursing 

homes (64 of 242) operate with waivers of this requirement. According to a 

CMS regional office official, at least 50 of these nursing homes are 

unsprinklered and use the corridor as part of the air return system. 

Similarly, 60 nursing homes in Wisconsin have a waiver of this same 

standard, primarily for using the corridor as part of the air return system; 

according to state officials, some of these homes are not fully sprinklered. 

Federal fire safety standards have always prohibited the use of facility 

corridors as an air return in lieu of individual air return vents in resident 

rooms because such an arrangement could accelerate the spread of smoke 

during a fire, particularly in an unsprinklered facility. CMS guidance 

permits a waiver of this requirement in an unsprinklered facility if it has 

compensating features, such as a complete corridor smoke detection 

system, and its air handling system is designed to shut down automatically 

upon activation of the smoke detectors or fire alarm. However, an NFPA 

official told us that these features were insufficient and that there are no 

compensating features permitting a nursing home to operate safely with 

such a deficiency, irrespective of the home’s sprinkler status. Such 

 32CMS officials disagreed with this characterization, emphasizing that a waiver is granted to 

a specific home and therefore is not applicable to other nursing homes. However, we 

identified CMS program guidance that set out criteria for granting specific types of waivers, 

demonstrating that waivers have been used to set across-the-board nursing home fire 

safety standards. 

Waivers of Federal Fire Safety 

Standards Pose a Serious 

Hazard in Some Unsprinklered 

Nursing Homes 
Page 23 GAO-04-660 Nursing Home Fire Safety 

facilities, he indicated, should be required to correct the deficiency and 

discontinue the use of the corridor as an air return. 

According to OSCAR data, standards for allowable construction type and 

sprinkler installation are also frequently not met.33 As of December 2003, 

approximately 15 percent of nursing homes nationwide (2,440 of 16,334) 

were cited for failure to meet one or both of these standards on their most 

recent surveys, and about one in six were not required to correct the 

deficiency by virtue of a waiver. While only about 2 percent of nursing 

homes nationally operate with construction-type or sprinkler waivers, 

these percentages are much higher in some states. In Iowa, for example, 

15 percent of all nursing homes (68) have waivers of construction-type 

and/or sprinkler standards. According to a CMS official, many of these 

facilities are unsprinklered one-story buildings of unprotected 

noncombustible or protected wood-frame construction—homes that 

federal fire safety standards require to be sprinklered.34 However, CMS 

guidelines allow a waiver of the sprinkler requirement in such facilities if 

(1) all hazardous areas are sprinklered; (2) an automatic fire detection 

system is provided throughout the building, which is designed to activate 

an alarm and close all doors in fire partitions; (3) resident rooms are 

separated from each other by at least 1-hour fire-rated construction; and 

(4) the response time and capability of the local fire department is 

adequate. 

According to a CMS official, many of these Iowa facilities received 

construction-type and sprinkler waivers for many years even though some 

lacked the adequate fire detection and containment features required by 

federal fires safety standards, posing a serious fire hazard for residents: 

• One protected wood-frame Iowa facility had waivers for construction type 

and sprinklers even though it lacked smoke detectors throughout and 

resident rooms were not adequately separated from each other as called 

for in CMS guidelines. In addition, the facility was cited for a deficiency 

and subsequently received a waiver for a lack of corridor smoke detectors, 

which were required by the applicable edition of federal standards. The 

 33Construction type refers to whether combustible or noncombustible materials were used 

to build a facility and to the number of floors. An unsprinklered facility that is required to 

be fully sprinklered might be cited for a deficiency of construction standards, sprinkler 

standards, or both. 

34“Protected” refers to construction materials designed or rated to withstand fire for a 

minimum of 1 hour. 
Page 24 GAO-04-660 Nursing Home Fire Safety 

facility currently has a temporary waiver to complete installation of a 

sprinkler system. 

• Another one-story wood frame facility had construction-type and sprinkler 

waivers despite a lack of smoke detection in both corridors and resident 

rooms.35 In addition, the facility received a temporary waiver of HVAC 

requirements in order to consult with an engineer about ventilation system 

modifications. The basement corridor was used as part of the return air 

system, and exhaust fans in three of four wings of the building were not 

properly ducted to the outside. 

We also found that inappropriate combinations of waivers, which could 

pose a serious risk for residents, are sometimes granted. For example, the 

older unprotected section of a noncombustible facility in Wisconsin was 

granted waivers for (1) a lack of sprinklers in a construction type that 

required sprinklers, (2) use of the corridor as an air supply, (3) corridor 

walls that did not extend to the roof deck, and (4) incomplete smoke 

barrier walls. Such a combination of structural features could greatly 

facilitate the spread of smoke in the event of fire. Waiver application 

materials for this facility inaccurately indicated the presence of complete 

smoke barrier walls, which was used as a partial justification of waivers of 

construction type and corridor-wall deficiencies. 

Some FSES-certified nursing homes lack adequate compensating features 

for the absence of sprinklers, posing a significant risk to resident safety in 

the event of a fire. As of December 2003, 7 percent of all nursing homes 

nationwide (1,138) were certified using FSES. These homes were located 

in 30 states. According to a CMS official, FSES is used by many nursing 

homes as a means of demonstrating an equivalent level of fire protection 

in order to avoid costly corrective measures, such as the installation of 

sprinklers, which would otherwise be required for the facility to meet all 

the prescriptive provisions of the code. Compensating features that may 

allow an unsprinklered home to meet the overall fire protection 

requirements include (1) higher- than-required fire resistance rating of 

interior construction and finish, (2) smoke detectors and alarms in 

individual resident rooms in addition to corridors, (3) multiple routes of 

 35The type of construction was unclear from the available documentation. While the 

statement of deficiencies from the facility survey indicated the one-story facility was of 

protected wood-frame construction, the FSES documentation identified it as unprotected 

wood-frame construction. According to CMS guidance, no waiver of sprinkler requirements 

may be granted for unprotected wood construction. 

Some FSES-Certified Nursing 

Homes Lack Adequate 

Compensating Features for 

Sprinklers 
Page 25 GAO-04-660 Nursing Home Fire Safety 

evacuation from resident rooms, or (4) mechanically assisted smoke 

control systems. 

We identified cases of FSES assessments in unsprinklered facilities that 

were (1) not evaluated correctly by the state survey agency, (2) not 

updated as facility conditions changed, and (3) used inappropriately in 

combination with waivers. According to an NFPA official, FSES should 

not be used in combination with waivers. 

• An unsprinklered Pennsylvania facility was certified based on an FSES 

assessment conducted in January of 2004, using the new 2000 federal 

standards. The building was assessed on FSES as a one-story unprotected 

noncombustible construction type. However, the facility is a two-story 

structure that should not have received a passing score on FSES, 

according to federal guidelines. The facility should have been required to 

install sprinklers or seek a waiver from CMS. 

• Another unsprinklered facility in Pennsylvania continued to be certified 

for several years based on FSES even though uncorrected deficiencies 

identified on state surveys should have caused the facility to receive a 

failing score.36 The facility originally failed FSES in 1995, but indicated firerated corridor doors would be added in certain areas and the number of 

evacuation routes would be increased in order to achieve a passing score. 

Although it was subsequently cited for deficiencies in resident evacuation 

and corridor openings that would have generated a failing score on FSES, 

the facility continued to be certified based on this evaluation. According to 

CMS guidelines, a new FSES is required when facility conditions change. 

• At one unsprinklered Iowa facility, state surveys identified multiple 

deficiencies for nonallowable construction type; failure to maintain fire 

rating of corridor walls; incomplete smoke barriers; and lack of sprinklers 

that the facility attempted to address through a combination of corrective 

action, temporary waivers, and FSES. Although the facility failed FSES in 

2003, the statement of deficiencies indicated that certain deficiencies 

would not have to be corrected because the home had achieved a passing 

score on FSES. Although the facility was subsequently required to install a 

complete sprinkler system in 2004, the combination of fire safety 

deficiencies had clearly posed a risk to resident safety for many years. 

 36This facility was of unprotected noncombustible construction, requiring sprinkler 

protection according to federal standards. 
Page 26 GAO-04-660 Nursing Home Fire Safety 

State and federal oversight of nursing home fire safety is inadequate. 

Postfire investigations by Connecticut and Tennessee revealed 

deficiencies that existed, but were not cited, during prior surveys. Those 

deficiencies were cited during Connecticut’s but not during Tennessee’s 

postfire investigation. Nationally, the wide variability among states in 

reported fire safety deficiencies suggests that other states may also be 

missing or failing to cite deficiencies, and the results of federal 

comparative fire safety surveys demonstrate that state surveyors either 

miss or fail to cite all fire safety deficiencies. While CMS provides 

oversight information to the public on its Nursing Home Compare Web 

site, the Web site currently lacks data on fire safety deficiencies or the 

sprinkler status of homes. CMS provides limited oversight of state survey 

activities to address the fire safety survey inconsistencies we identified. 

CMS regional offices (1) do not fully comply with the statutory 

requirement to conduct a minimum number of federal monitoring surveys 

to assess state surveyors’ performance on the fire safety component of 

state surveys, (2) lack basic data to assess the appropriateness of 

uncorrected deficiencies, (3) infrequently review state trends in citing fire 

safety deficiencies, and (4) provide insufficient oversight of deficiencies 

that are waived or that homes need not correct because of claimed 

compensating fire safety features. 

Postfire investigations by the Connecticut and Tennessee state survey 

agencies revealed deficiencies that state surveyors did not identify on 

prior surveys (see table 5). As part of its postfire investigation, the 

Connecticut survey agency identified two fire safety deficiencies not cited 

during a survey just 1 month before the fire that found the home to be 

deficiency free. First, the home failed to control and monitor smoking for 

21 of the approximately 48 residents who were included in the sample 

during the state’s postfire investigation, including the resident who 

allegedly started the fire. Although surveyors did not review the records of 

this resident prior to the fire, they subsequently determined that she was 

inappropriately classified as an independent smoker even though she was 

cognitively impaired and had a history of burning herself. In addition, of 

the 21 residents identified with smoking-related deficiencies after the fire, 

3 of these residents were included in the resident sample during the 

State and Federal 

Oversight of Nursing 

Home Fire Safety Is 

Inadequate 

Connecticut and 

Tennessee Surveyors Did 

Not Identify Deficiencies 

that Existed Prior to Fires 
Page 27 GAO-04-660 Nursing Home Fire Safety 

prefire survey, but no problems were identified at that time.37 During the 

prefire survey, surveyors checked to determine if the facility had a policy 

in place to conduct a smoking assessment of each resident but did not 

systematically verify the accuracy of such assessments. Connecticut 

officials told us that if surveyors happen to observe potential problems, 

such as unsafe smoking during the course of a survey, they ensure that the 

residents involved are accurately assessed for smoking and that 

appropriate supervision is being provided. Otherwise, surveyors assume 

that resident assessments have been conducted accurately and that 

smoking supervision is adequate. Second, staff interviews conducted after 

the fire to determine where each nursing home staff person was when the 

fire began and how each responded revealed that (1) the staff did not 

implement the home’s fire plan on the night of the fire, and (2) the home 

failed to conduct required quarterly fire drills during the night shift, relying 

instead on a review of written procedures.38 The prior survey was based on 

inaccurate documentation provided by the nursing home and was 

conducted during the daytime when night shift staff were not available for 

interviews. The state survey agency concluded that these serious 

deficiencies contributed to the deaths of 16 residents and cited the 

Hartford nursing home with two actual harm fire safety deficiencies after 

the fire. Connecticut officials stated that the investigation following the 

fire was much more extensive than a routine fire safety survey and 

focused on specific issues that surfaced soon after the fire. In addition, 

while Connecticut surveyors spend on average about 5 hours on-site 

during a standard fire safety survey, the state agency was on-site for 4 days 

following the fire and continued to interview staff throughout its 3-month 

investigation. 

 37During the prefire survey, Connecticut surveyors reviewed the records of 25 residents, 

including smokers and non-smokers and residents with and without cognitive impairments. 

Following the fire, approximately 48 residents were a part of the state’s investigation—

focusing specifically on residents who smoked and had cognitive impairments. 

38While not a federal requirement, Connecticut and Tennessee fire safety surveyors 

routinely pull the fire alarm during fire safety surveys to determine if staff follow the 

home’s fire plan. 
Page 28 GAO-04-660 Nursing Home Fire Safety 

Table 5: Violations of Federal Standards in Hartford and Nashville Nursing Home Fires Not Identified during Prior Surveys 

 Violations 

Federal standard Hartford nursing home Nashville nursing home 

Smoking policy Smoking by residents classified as not 

responsible shall be prohibited except 

when under direct supervision. 

Facility failed to control and monitor 

smoking for 21 residents—including 

3 whose records were reviewed 

during the prior survey, but no 

violations were identified at that time. 

Not applicable. 

Staff response Fire drills are conducted quarterly on all 

shifts, and all staff are familiar with 

facility fire plan and appropriate 

procedures. 

Staff may have failed to close all 

resident room doors, and all 

designated staff did not respond with 

fire extinguishers as called for in the 

fire plan. 

Not clear from available 

investigations. 

HVAC system Air handling system is required to shut 

down automatically when fire alarm is 

triggered to prevent the spread of 

smoke. 

Not applicable.a Air handling system may have 

failed to shut down as required, 

contributing to spread of smoke.

Vertical openings Vertical openings or penetrations 

between floors are required to be 

protected (fire rated and resistant to the 

passage of smoke). 

Not applicable.b Unprotected vertical opening in 

group shower room ceiling 

where penetrated by plumbing 

allowed smoke to migrate to 

upper floors of the building. 

Sources: GAO analysis of information provided by Connecticut and Tennessee state survey agencies. 

a

The facility did not have a central heating and cooling system with ductwork but rather relied on wallmounted heat pumps in each resident’s room. 

b

The facility is only one-story. 

In contrast to Connecticut’s investigation, the Tennessee state survey 

agency’s investigation was less thorough and did not cite any deficiencies 

following the fire. A Tennessee fire safety surveyor who conducted a walkthrough of the facility the day after the fire identified, but did not follow up 

on, a number of potential deficiencies that may have contributed to the 
Page 29 GAO-04-660 Nursing Home Fire Safety 

loss of life.39 During his walk-through, the fire safety surveyor noted that 

the fire had been largely contained to the second floor area where it 

originated and that a large amount of smoke had traveled to the upper two 

floors—where one-third of the residents died as a result of smoke 

inhalation. He concluded, based on the smoke stains on the heating and 

cooling registers and around other openings, that some of the smoke 

traveled through the ventilation system to individual resident rooms and 

through openings around shower room plumbing that ran between floors. 

Although he suspected that the ventilation system might not have shut 

down as required when the fire alarm was activated, he never investigated 

to determine if a deficiency should have been cited, and according to CMS 

fire safety specialists, the unprotected vertical opening around the shower 

room pipes should have been cited by the state on previous surveys and 

corrected years ago.40

Although the Nashville home was cited for poor implementation of its fire 

plan on each of its four most recent surveys, the state survey agency never 

interviewed nursing home staff directly to determine if this recurring 

problem contributed to the loss of life during the fire. According to CMS 

and NFPA officials who have investigated serious fires, one of the critical 

initial steps is to separately interview staff who were present during the 

fire to determine whether they followed the home’s fire plan. Instead, a 

Tennessee state surveyor obtained a description of how the staff 

responded from the nursing home’s administrator and a corporate vice 

president who were not inside the building when the fire began. Thus, the 

state agency never established a clear chronology of the staff’s response, 

including whether they closed resident room doors to contain the fire and 

 39Tennessee survey agency officials said that their investigation was limited because the 

fire was treated as a crime scene An official with the Nashville Fire Department told us that 

the facility was treated as a crime scene with restricted access for less than 24 hours. Once 

the restriction was lifted, he indicated, nothing prevented the state survey agency from 

following up on concerns identified during its walk-through. 

40Federal fire safety survey protocols do not require state surveyors to test the ventilation 

shut-off safety feature during fire safety surveys by pulling the fire alarm to see if 

ventilation systems shut down as required. Because Tennessee typically only checks such a 

fire safety feature on initial surveys, it may not have been reviewed by the state survey 

agency since the home began operating in 1967. 
Page 30 GAO-04-660 Nursing Home Fire Safety 

smoke.41 CMS officials were unaware of the limited nature of the 

Tennessee state survey agency’s fire investigation even though it is CMS’s 

responsibility to monitor state fire safety survey performance. 

The wide interstate variability in reported fire safety deficiencies and the 

results of federal monitoring surveys suggest that the understatement of 

deficiencies during fire safety surveys may not be limited to Connecticut 

and Tennessee. As shown in appendix I, about 59 percent of all nursing 

homes nationwide were cited for fire safety deficiencies on their most 

recent surveys, but this proportion ranged from about 10 percent in 

Kentucky to 99 percent in North Dakota.42 Figure 2 shows the considerable 

variation that exists in states with at least 100 nursing homes.43

 41The nursing home’s fire plan also called for staff to shut off blowers, fans, and air 

conditioners during a fire to prevent the spread of fire and smoke. In addition, staff were 

expected to prevent residents from reentering the building during a fire. With the exception 

of the resident who died in the room where the fire began, all the victims died as a result of 

smoke inhalation, and one resident was severely injured upon reentering the building after 

having been safely evacuated. Because of the limited investigation, it is unclear to what 

extent the nursing home staff followed these two fire plan procedures designed to 

minimize the loss of life. 

42Because actual harm is reserved for fire-related injuries, most fire safety deficiencies are 

cited at less than actual harm. Of the approximately 39,000 fire safety deficiencies cited 

nationally during the most recent nursing home surveys, 19 states cited a total of 43 

deficiencies at the level of actual harm or higher. 

43We excluded 12 states and the District of Columbia from our analysis because they had 

fewer than 100 homes, and even a small number of homes with fire safety deficiencies 

produces a relatively large percentage of homes with such deficiencies. The 12 states 

excluded were Alaska, Delaware, Hawaii, Idaho, Nevada, New Hampshire, New Mexico, 

North Dakota, Rhode Island, Utah, Vermont, and Wyoming. 

Wide Interstate Variability 

in Reported Deficiencies 

as well as Results of 

Federal Surveys Suggest 

that Fire Safety 

Deficiencies Are 

Understated 
Page 31 GAO-04-660 Nursing Home Fire Safety 

Figure 2: Percentage of Nursing Homes Reported to Have Fire Safety Deficiencies 

on Their Most Recent Surveys in States with at Least 100 Homes 

We discussed this variability with officials in CMS’s central office and each 

of its 10 regions. A CMS central office fire safety specialist told us that 

some states enforce the federal standards more rigorously than other 

states and that the variability in survey deficiencies suggests that some 

states do not cite all the deficiencies they find. Officials in 6 of the 10 CMS 

regions confirmed that state surveyors do not always cite the deficiencies 

identified during surveys. We were told that state surveyors had 

(1) allowed nursing homes to correct identified problems without 

documenting the deficiencies, (2) granted unofficial waivers by not citing 

deficiencies and not requiring the homes to correct the deficiencies, and 

(3) cited deficiencies under state licensure authority but failed to cite them 

as federal deficiencies. For example, for over 2 years, surveyors in one 

state were whiting-out deficiencies on the survey forms and reporting that 

Percentage of

nursing homes

with reported

fire safety deficiencies

Number of states with at least 100 nursing homes

Fewer than 25

From 25 to 50 

From 51 to 75 

More than 75

Source: GAO analysis of OSCAR data as of December 1, 2003.

4

13

13

8

0 3 6 9 12 15
Page 32 GAO-04-660 Nursing Home Fire Safety 

the homes had no fire safety deficiencies. Some of the state’s survey forms 

read “per fire marshal, do not cite.”44

The results of federal comparative fire safety surveys also demonstrate 

that state surveyors either miss or fail to cite all fire safety deficiencies. A 

comparative survey involves a federal survey team conducting a complete, 

independent survey of a home shortly after a state’s survey to compare 

and contrast the findings. Of the 40 comparative surveys that assessed fire 

safety standards in fiscal year 2003, federal surveyors identified on average 

more than two fire safety deficiencies per home that were either missed or 

not cited by state surveyors, but in one region the average number of such 

deficiencies was about five.45 Some of the deficiencies found by federal 

surveyors were potentially serious, including the absence of required 

sprinkler systems, improper maintenance of sprinkler systems, inadequate 

building construction to contain fire and smoke during a fire, and failure to 

conduct routine fire drills.46 Some of the same deficiencies not cited by 

Connecticut and Tennessee surveyors prior to the fires likely contributed 

to the spread of smoke during the two nursing home fires in 2003. 

Appendix II identifies examples of deficiencies identified during fiscal year 

2003 federal comparative fire safety surveys that were either missed or not 

cited by state surveyors on standard surveys. While several regional office 

officials stated that comparative fire safety surveys could be used to 

reduce the variability in how states conduct fire safety surveys, CMS 

central office does not review comparative survey results nationally to 

identify training and refresher topics for state surveyors. 

 44As a result of a CMS regional office investigation, a state official was ultimately charged 

with falsifying fire safety survey forms. While the official admitted to misrepresenting 

information on fire safety survey forms, a federal jury acquitted her in February 2004. 

According to a CMS regional office official, criminal intent could not be proven. 

45In some cases, state surveyors identified deficiencies that federal surveyors did not cite. 

Several regions stated that this situation typically occurs when homes correct deficiencies 

identified by the state before federal surveyors arrive to conduct their survey. 

46Our examination of quality-of-care comparative surveys has consistently found that 

federal surveyors find serious deficiencies missed or not cited by state surveyors in a 

sizeable percentage of surveys conducted. See U.S. General Accounting Office, Nursing 

Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance 

of Enhanced Oversight, GAO-03-561 (Washington, D.C.: July 15, 2003). 
Page 33 GAO-04-660 Nursing Home Fire Safety 

In some cases, the deficiencies missed or not cited during state surveys 

were so basic that they raise a question about the preparation or training 

of state surveyors or the thoroughness of state surveys: 

• State surveyors incorrectly classified nursing home construction types, 

thus failing to identify buildings that were required to be sprinklered under 

federal standards. 

• State surveyors failed to identify the lack of a fire-rated ceiling that would 

resist the spread of fire for 1 hour in a one-story wood-frame nursing 

home. 

• State surveyors failed to identify that approximately 80 percent of a 

home’s resident rooms had sidewall-mounted sprinkler heads that would 

not work in the event of a fire because they were blocked by privacy 

curtains hanging in the room. 

• State surveyors incorrectly surveyed additions and major renovations in 

facilities across the state by using less stringent federal standards that 

applied to the original nursing home structures. 

• State surveyors missed obvious fire safety deficiencies, such as the use of 

plywood rather than drywall for corridor walls, unprotected hazardous 

areas, hollow core doors that were required to be solid, and facilities 

lacking fire alarms.47

A CMS fire safety specialist who identified some of these missed 

deficiencies told us that they were overlooked because of a lack of rigor 

on the part of state surveyors.48 According to this official, conducting a fire 

safety survey involves more than simply walking through a nursing home. 

Because floors, walls, and ceilings mask many building construction 

features, surveyors need to take additional steps to verify that a home 

meets federal standards. Such steps could include (1) removing electrical 

switch plates to verify the thickness and type of material used for walls; 

(2) using a ladder to look above a false ceiling to ensure that there are no 

hidden openings in the corridor walls that would allow smoke to enter 

resident rooms; and (3) checking attics to ensure that they contain 

sprinklers, as required. Moreover, we were told it is important during each 

annual survey to thoroughly examine a building’s fire safety elements 

 47Homes completely lacking fire alarm systems are to be cited for immediate jeopardy. 

48A Connecticut survey agency official stated that missed deficiencies can also be 

attributed to the lack of surveyor training and the infrequency of fire safety training 

courses offered by CMS. In addition, while we did not look at this issue in depth, officials in 

several regional offices stated that inadequate surveyor training and lack of experience 

may explain some of the interstate variability in reported fire safety deficiencies. 
Page 34 GAO-04-660 Nursing Home Fire Safety 

because features do change over time due to routine maintenance and 

renovation. For example, homes may replace their false ceilings with nonfire-rated material, add new light fixtures that block sprinkler coverage, or 

install ceiling fans that interfere with the operation of smoke detectors. In 

addition, mechanical systems may not always work as intended and 

should be checked routinely during state surveys. 

OSCAR data on the duration of on-site fire safety surveys also raised 

questions about the thoroughness of some state fire safety surveys. For 

current surveys, the average amount of time spent on-site conducting a fire 

safety survey is about 5 hours, nationally. In 16 states, 25 percent or more 

of homes’ current surveys occurred in 2 hours or less (see table 6).49

According to CMS officials, a survey of 2 hours or less may be adequate 

because of surveyor familiarity with a facility, the small size of some 

facilities, or the existence of sprinklers that mitigate certain deficiencies. 

However, regional office officials identified concerns in at least five states 

where surveyors may not be spending enough time in facilities to 

adequately assess their compliance with federal standards. 

Table 6: States with Large Proportions of Current Fire Safety Surveys Conducted in 

2 hours or Less 

Percentage of homes surveyed in 

2 hours or less States 

From 25 to 50 percent Colorado, Indiana, Maine, Minnesota, 

Oklahoma, South Carolina, and Virginia 

From 51 to 75 percent Georgia, Iowa, Kentucky, Nebraska, 

Vermont, and Washington 

More than 75 percent Maryland, Oregon, and Rhode Island 

Source: GAO analysis of OSCAR data as of January 22, 2004. 

The CMS Web site that provides information on the results of nursing 

home quality-of-care oversight lacks fire safety data. Since 1998, CMS has 

shown a strong commitment to providing the public with information on 

nursing homes through its Nursing Home Compare Web site.50 The Web 

site includes information on state quality-of-care surveys, other measures 

of quality based on resident assessment data, complaint investigations, 

and staffing levels for individual nursing homes. Although fire safety 

 49However, in 22 states, fewer than 5 percent of homes have such quick surveys. 

50See http://www.medicare.gov/NHCompare. 
Page 35 GAO-04-660 Nursing Home Fire Safety 

deficiency data available to the public were initially included on CMS’s 

Web site, they were subsequently removed because of concern over how 

to portray deficiencies that remain uncorrected because of waivers or 

FSES. However, one state survey agency (Pennsylvania) found a way to 

clearly indicate whether deficiencies had to be corrected.51 In addition, the 

CMS Web site contains no information on whether a nursing home has 

automatic sprinklers or smoke detectors in resident rooms. 

CMS provides insufficient oversight of state survey activities to address 

the fire safety survey inconsistencies we identified. In general, CMS 

regional offices (1) do not fully comply with the statutory requirement to 

conduct federal monitoring surveys; (2) lack basic data to assess the 

appropriateness of waivers and FSES, especially in unsprinklered 

facilities; (3) infrequently review state trends in citing fire safety 

deficiencies; and (4) provide insufficient oversight of deficiencies that are 

waived or that homes need not correct because of compensating fire 

safety features. 

CMS’s evaluation of state surveyors’ performance has not routinely 

included fire safety as part of the statutory requirement to annually 

conduct federal monitoring surveys in at least 5 percent of surveyed 

nursing homes in each state.52 Table 7 contrasts the number and type of 

annual federal monitoring surveys that included quality-of-care and fire 

safety standards. While 871 federal monitoring surveys focused on qualityof-care standards in fiscal year 2003, only 40 such surveys assessed fire 

safety—all of them comparative.53 Six of the 10 CMS regional offices 

included fire safety as part of federal monitoring surveys in fiscal year 

2003, but the number of such fire safety assessments varied from four per 

state to none. Overall, 27 states had no federal assessments of fire safety in 

this time period. Officials in all 6 of the regional offices that assessed fire 

 51See http://app2.health.state.pa.us/commonpoc/nhlocatorie.asp. 

52A federal monitoring survey may be either comparative or observational. A comparative 

survey is conducted within 2 months of the state survey and provides an independent 

evaluation of whether state surveyors identified all deficiencies of federal standards and an 

observational survey allows federal surveyors who accompany a state survey team to 

observe the team’s performance. 

53Some regions conducted informal fire safety training surveys with state surveyors. In 

addition, while one region does not conduct fire safety comparative surveys, its fire safety 

specialist does cite fire safety deficiencies noted while on-site during quality-of-care 

comparative surveys. 

CMS Oversight of State 

Fire Safety Activities Is 

Insufficient 

Evaluation of State Surveyors’ 

Performance Is Limited 
Page 36 GAO-04-660 Nursing Home Fire Safety 

safety told us that they lacked sufficient staff to increase the number of 

surveys that included fire safety. While acknowledging that CMS guidance 

does not specifically direct regions to assess compliance with fire safety 

standards when conducting federal monitoring surveys, CMS officials 

agreed that such assessments are mandatory and that they need to clarify 

this matter with regional offices. 

Table 7: Comparison of the Number and Type of Federal Monitoring Surveys 

Including Quality-of-Care and Fire Safety Standards, Fiscal Year 2003 

 Federal monitoring surveys 

Quality-of-care Fire safety 

Total surveys 871 40a

Proportion of homes 

surveyed 

More than 5 percent About .2 percent 

Number of states in which 

federal monitoring surveys 

were conducted 

All states plus the District of 

Columbia 

23 states plus the District of 

Columbia 

Proportion comparativeb 20 percent All 

Proportion observational 80 percent None 

Source: CMS. 

a

Our analysis excluded 15 surveys in four of the six regions that were conducted either before the 

state survey or more than 60 days after the state survey. We excluded these surveys because by 

statute a federal survey must begin within 2 months of the state’s survey to ensure a valid 

comparison. 

b

We noted in 1999 that comparative surveys, though insufficient in number, were the most effective 

technique for assessing state agencies’ abilities to identify deficiencies in nursing homes because 

they constitute an independent evaluation of the state survey. See U.S. General Accounting Office, 

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better Ensure Quality, 

GAO/HEHS-00-6 (Washington, D.C.: Nov. 4, 1999). 

OSCAR data limitations and inconsistent use of available information by 

CMS regions hamper CMS’s efforts to oversee state fire safety activities. 

While OSCAR identifies homes cited for deficiencies on fire safety surveys, 

it is unable to distinguish between deficiencies cited for sprinklered and 

unsprinklered homes.54 As previously discussed, information on the extent 

of sprinkler coverage at a home is important both when initially 

considering allowing uncorrected deficiencies through waivers and FSES 

and when reevaluating the appropriateness of uncorrected deficiencies—

 54There is no data field in OSCAR to capture the sprinkler status of nursing homes. Another 

CMS database has the capacity to store nursing home sprinkler coverage information; 

however, CMS does not require states to report such data. 

Data Limitations and 

Inconsistent Use of Available 

Information Hamper CMS 

Oversight 
Page 37 GAO-04-660 Nursing Home Fire Safety 

especially in unsprinklered nursing homes. Such information is also 

needed to develop a reliable estimate of the cost of retrofitting older 

homes with sprinklers. During the course of our work, we shared our 

concern about the lack of such data and, as a result, CMS officials told us 

that they are in the process of developing a new data field on sprinkler 

coverage for the form used by surveyors to collect data on a facility’s 

compliance with federal fire safety standards. 

Despite the variability in fire safety deficiency patterns across states, CMS 

makes limited use of OSCAR data to identify potential problems in state 

adherence to federal requirements and the need for training. CMS central 

office does not review fire safety deficiency patterns, and only 3 of the 10 

regions routinely review state-level OSCAR data on fire safety deficiencies 

for the states in their regions. During such reviews, 1 region discovered 

that surveyors in a particular state had cited only five fire safety 

deficiencies at the 100 homes surveyed. The region used the data as an 

opportunity to review federal fire safety requirements with state surveyors 

and, as a result, the state surveyors are now citing deficiencies that had 

previously been missed or not cited. Another region noticed that state 

surveyors were improperly citing potentially serious deficiencies at the 

lowest scope and severity level. While facilities are expected to address 

fire safety deficiencies at all levels, a regional office official stated that 

homes with low scope and severity levels might receive less scrutiny than 

facilities with higher levels. Since CMS discussed the matter with the state, 

state surveyors cite deficiencies at levels that more appropriately reflect 

the extent and seriousness of the problems identified. The region also uses 

OSCAR data to identify specific state surveyors who may need additional 

training. 

Routinely reviewing OSCAR data would also help CMS ensure that state 

surveys, including assessments of fire safety, are taking place within the 

time frames required by statute. For example, we found that 31 percent of 

a state’s surveys in one region and 9 percent of all surveys in a different 

region were not conducted within 15 months of the prior fire safety 

survey, as required by statute. Neither of the regions overseeing these 

states nor CMS central office routinely examined OSCAR data to 

determine if fire safety surveys occurred within statutory time frames. 

CMS regional office staff are not reviewing and approving all renewal 

requests for waivers of federal fire safety standards nor are they reviewing 

the results of FSES, as required by CMS guidance. Moreover, half of the 10 

regions do not have fire safety specialists on staff and some regions allow 

nonspecialists to conduct waiver reviews. Although a regional office may 

CMS Does Not Review All 

Waiver Renewal Requests and 

FSES Results 
Page 38 GAO-04-660 Nursing Home Fire Safety 

waive certain requirements and allow deficiencies to remain uncorrected, 

such deficiencies must be identified on subsequent surveys and any 

waivers must be periodically renewed and reviewed. We found that four 

regions either did not require states to submit requests for waiver 

renewals or that states in those regions did not submit waiver renewal 

requests.55 Since the circumstances that led to the approval of a waiver 

may change, periodic renewal of waivers is important. For example, based 

on the lessons of the Tennessee nursing home fire in September 2003, the 

Atlanta regional office raised a question about the renewal of waivers for 

at least 50 homes in Arkansas. For many years, these unsprinklered homes 

had received a waiver for a ventilation system requirement that could 

allow smoke to spread to resident rooms during a fire. 

We also found considerable variability in the expertise of CMS regional 

office staff tasked with reviewing waiver requests. Overall, 5 of the 10 

regional offices currently have fire safety specialists who are either civil or 

mechanical engineers or have a significant amount of fire safety 

experience or training.56 NFPA commented that civil or mechanical 

engineers are not necessarily qualified in fire safety and that fire 

protection engineers would be a good addition to CMS staff. In contrast, 2 

regions have either public health or health insurance specialists conduct 

waiver reviews, whereas a third region has its waivers reviewed by a fire 

safety specialist in another CMS regional office. In a fourth region, two of 

the three health insurance specialists who conduct waiver reviews have 

not taken CMS’s basic fire safety training. According to the staff, they 

generally accept the state’s recommendation with little independent 

review. Until one regional office decided to hire its own fire safety 

specialist in 2002, waiver review was treated as a clerical function. 

According to CMS officials, the decision not to have a full-time fire safety 

specialist in each region was made in the early 1980s and was based on 

resource constraints. They pointed out that regions lacking sufficient fire 

 55One CMS regional office did not require a particular state to submit waiver requests or 

FSES results because the state was operating under a later edition of the fire safety code. 

From February 1997 through September 2003, CMS allowed the state to implement the 

1994 NFPA life safety code in lieu of the older federal standards, which were based on 

NFPA’s 1985 code. During these 6 years, there was no federal oversight of the state’s 

enforcement of fire safety standards for nursing homes. 

56Three of the specialists in these five regions devote all of their time to fire safety oversight 

activities while the other two are part-time fire safety specialists. As of April 2004, a sixth 

region was working to fill a vacancy due to the retirement of its fire safety specialist. A civil 

engineer is trained in the design and construction of public works, including buildings, 

roads, and bridges. 
Page 39 GAO-04-660 Nursing Home Fire Safety 

safety expertise may obtain assistance from specialists either in CMS 

central office or in other regions. 

Eight of 10 regional offices do not adhere to CMS’s policy that requires 

regions to review FSES results as an alternative way for nursing homes to 

comply with federal fire safety standards. Five regions currently lack a fire 

safety specialist to conduct the reviews. According to an NFPA technical 

expert, it is critical for the individuals who review FSES results to have 

both an extensive knowledge of the standards and the ability to distinguish 

among different construction types and materials. We believe that this is 

particularly important in homes that lack sprinkler protection but claim to 

have compensating construction features. A regional office fire safety 

specialist who does not routinely review FSES results told us that he was 

aware of two unsprinklered homes where the passing scores determined 

by the state were incorrect. After he discovered the errors, one home 

agreed to install a sprinkler system, and the other moved residents to a 

facility with sprinkler protection. 

Our examination of the lessons learned from the Hartford and Nashville 

nursing home fires in which 31 residents died found systemic problems 

with the adequacy and enforcement of federal fire safety standards that go 

well beyond these two tragic events. As a result of these fires, NFPA is 

now actively considering incorporating a sprinkler retrofit requirement 

into its 2006 update of the standards, a move supported by the nursing 

home industry. Given industry concerns about the cost and the need for a 

transition period for homes to come into compliance, older homes will 

likely continue to operate without sprinklers for several years. Because of 

the uncertainty concerning whether or when the fire safety standards will 

be revised and implemented, we believe that certain actions are needed 

now to better protect residents in the event of a fire in an unsprinklered 

nursing home. 

Federal oversight of state fire safety activities is currently inadequate to 

ensure that existing standards are being enforced. For example, CMS does 

not routinely include the fire safety component as part of its statutory 

mandate to conduct annual federal monitoring surveys intended to assess 

state survey agency performance, particularly in unsprinklered facilities. 

Moreover, CMS’s review of deficiencies that nursing homes do not correct 

because of waivers or FSES is weak. Because it lacks data on the extent to 

which facilities have sprinklers, it is currently unable to quickly focus its 

attention on uncorrected deficiencies in unsprinklered facilities. Despite 

the availability of information on oversight of nursing home quality 

Conclusions 
Page 40 GAO-04-660 Nursing Home Fire Safety 

through CMS’s Nursing Home Compare Web site, no comparable 

information on fire safety is currently available. Thus, consumers lack a 

complete picture of a home’s compliance with federal health and safety 

requirements when selecting a facility, including information on whether 

the home has automatic sprinklers or smoke detectors in resident rooms. 

Action by CMS is required to ensure that an appropriate balance is struck 

between resident safety and a concern about costs when updating federal 

fire safety standards. For example, although commonsense features such 

as smoke detectors in resident rooms have been shown to be effective in 

alerting staff to a fire while it is still relatively manageable, smoke 

detectors are not required in unsprinklered nursing homes. Furthermore, 

CMS has not yet developed a reliable cost estimate for retrofitting older 

homes with sprinklers, a critical issue as NFPA considers requiring all 

homes to have sprinklers. Finally, CMS acknowledges that fires are a test 

of the standards designed to safeguard both life and property, providing an 

opportunity to identify strengths and weaknesses. However, the agency 

missed an opportunity to obtain critical information on which to base 

decisions regarding future revisions to the standards when it did not 

conduct its own independent investigations of the Hartford and Nashville 

fires, as it has done in past multiple-death fires. 

To improve federal oversight of state fire safety activities, provide the 

public with important information about the fire safety status of nursing 

homes, and better ensure the adequacy of fire safety standards, we 

recommend that the Administrator of CMS take the following seven 

actions. 

• Ensure that CMS regional offices fully comply with the statutory 

requirement to conduct annual federal monitoring surveys by including an 

assessment of the fire safety component of states’ standard surveys, with 

an emphasis on unsprinklered homes. 

• Ensure that data on sprinkler coverage in nursing homes are consistently 

obtained and reflected in the CMS database. 

• Until sprinkler coverage data are routinely available in CMS’s database, 

work with state survey agencies to identify the extent to which each 

nursing home is sprinklered or not sprinklered. 

• On an expedited basis, review all waivers and FSES assessments for 

homes that are not fully sprinklered to determine their appropriateness. 

• Make information on fire safety deficiencies available to the public via the 

Nursing Home Compare Web site, including information on whether a 

home has automatic sprinklers. 

Recommendations for 

Executive Action 
Page 41 GAO-04-660 Nursing Home Fire Safety 

• Work with NFPA to strengthen fire safety standards for unsprinklered 

nursing homes, such as requiring smoke detectors in resident rooms, 

exploring the feasibility of requiring sprinklers in all nursing homes, and 

developing a strategy for financing such requirements. 

• Ensure that thorough investigations are conducted following multipledeath nursing home fires so that fire safety standards can be reevaluated 

and modified where appropriate. 

We provided a draft of this report to CMS, the Connecticut and Tennessee 

state survey agencies, and NFPA. CMS concurred with our findings and 

recommendations, stating that it has undertaken several initiatives to 

improve federal oversight of state fire safety surveys. (CMS’s comments 

are reproduced in app. III.) 

CMS commented that because protecting nursing home residents from fire 

hazards was an important goal, it conducted its own analysis of nursing 

home fire risk at the same time our study was underway. As a result, CMS 

has already taken steps to implement all seven of our recommendations. 

For example, CMS stated that because it is important for every resident 

room to have a smoke detector, it will pursue a regulatory change 

requiring their installation. Similarly, CMS plans to confirm the sprinkler 

status of each home during upcoming facility surveys and to enter this 

information in CMS’s database. CMS also plans to make both the sprinkler 

status and fire safety survey results available to the public on its Medicare 

Compare Web site by the summer of 2005. Finally, to fulfill the statutory 

requirement for annual federal monitoring surveys designed to assess the 

effectiveness of state fire safety surveys, CMS has reprioritized resources 

for a five-fold increase in comparative surveys to about 200 during fiscal 

year 2005, with a focus on unsprinklered nursing homes. Its goal is to 

accomplish the remaining approximately 700 observational surveys by 

redesigning regional office workplans. CMS also provided technical 

comments which we incorporated as appropriate. 

The Connecticut state survey agency provided technical comments, which 

we incorporated as appropriate. In discussing the state’s comments with 

survey agency officials, we were told that the agency now (1) reminds 

facilities that fire drills on all shifts must be more than a paper review of a 

home’s fire plan and (2) pays more attention to smoking-related issues 

during fire safety surveys, including obtaining a list of all smokers at the 

beginning of a survey. Based on our prior work, we believe that 

Connecticut’s, and likely other states’, experience underscores the risks of 

Agency, State, and 

NFPA Comments and 

Our Evaluation 
Page 42 GAO-04-660 Nursing Home Fire Safety 

relying on documentation without systematically verifying its accuracy 

through interviews and observation.57

NFPA provided technical comments, which we incorporated as 

appropriate. The Tennessee state survey agency did not comment on our 

draft. 

As arranged with your offices, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days after its 

issue date. At that time, we will send copies to the Administrator of the 

Centers for Medicare & Medicaid Services and appropriate congressional 

committees. We also will make copies available to others upon request. In 

addition, the report will be available at no charge on the GAO Web site at 

http://www.gao.gov. 

Please contact me at (202) 512-7118 or Walter Ochinko, Assistant Director, 

at (202) 512-7157 if you or your staffs have any questions. GAO staff who 

contributed to this report include Eric Anderson, Dean Mohs, and Paul M. 

Thomas. 

Kathryn G. Allen 

Director, Health Care—Medicaid 

 and Private Health Insurance Issues 

 57Our prior work found that nursing home records can contain misleading information or 

omit important data, making it difficult for surveyors to identify deficiencies during their 

on-site reviews. See U.S. General Accounting Office, California Nursing Homes: Care 

Problems Persist Despite Federal and State Oversight, GAO/HEHS-98-202 (Washington, 

D.C.: July 27, 1998). 
Appendix I: Percentage of Surveyed Nursing 

Homes Cited with Fire Safety Deficiencies on 

Their Most Recent Surveys, by State 

Page 43 GAO-04-660 Nursing Home Fire Safety 

State Number of homes surveyed

Percentage of surveyed homes

with fire safety deficiencies

North Dakota 84 98.8

Montana 101 97.0

Utah 90 96.7

Wyoming 39 94.9

Nevada 44 93.2

Michigan 431 92.1

South Dakota 113 88.5

Kansas 374 86.6

Texas 1,143 84.4

Pennsylvania 740 82.3

Iowa 454 79.7

Tennessee 337 78.6

New Mexico 81 76.5

Louisiana 314 74.5

Delaware 42 73.8

Arizona 135 73.3

Illinois 831 71.4

District of Columbia 21 71.4

Ohio 990 70.8

Georgia 360 70.8

Oregon 141 68.8

Alaska 14 64.3

Alabama 228 61.0

Florida 694 60.5

Nation 16,334 58.9

Wisconsin 408 56.4

North Carolina 423 56.3

Arkansas 242 56.2

Virginia 278 53.2

California 1,342 51.0

Mississippi 204 49.5

Colorado 216 48.2

New Jersey 356 48.0

Massachusetts 481 47.6

West Virginia 136 45.6

Appendix I: Percentage of Surveyed Nursing 

Homes Cited with Fire Safety Deficiencies on 

Their Most Recent Surveys, by State 
Appendix I: Percentage of Surveyed Nursing 

Homes Cited with Fire Safety Deficiencies on 

Their Most Recent Surveys, by State 

Page 44 GAO-04-660 Nursing Home Fire Safety 

State Number of homes surveyed

Percentage of surveyed homes

with fire safety deficiencies

New York 671 45.6

Washington 260 45.0

Missouri 534 44.0

Indiana 527 43.5

Maryland 243 40.7

Oklahoma 370 30.5

Rhode Island 95 28.4

Connecticut 252 26.6

Minnesota 425 25.7

New Hampshire 81 23.5

Vermont 43 23.3

Hawaii 45 22.2

Maine 119 21.9

Nebraska 228 21.5

Idaho 80 20.0

South Carolina 178 14.0

Kentucky 296 9.8

Source: GAO analysis of most recent state surveys in OSCAR as of December 1, 2003. 
Appendix II: Federal Comparative Survey 

Results for Fiscal Year 2003—Examples of 

Fire Safety Deficiencies Missed or Not Cited 

Page 45 GAO-04-660 Nursing Home Fire Safety 

CMS regional office 

(state) Federal fire safety standard 

Fire safety deficiencies missed or not cited by 

state surveyors 

Atlanta 

(Georgia) 

Corridor walls must be fire-rated, extend from 

the floor to the roof deck or floor above, and 

resist the passage of smoke. In a fully 

sprinklered facility, corridor walls may terminate 

at the underside of the ceiling, need not be firerated, and must only resist the passage of 

smoke. 

• Not all corridor walls extended to the roof deck to 

provide the minimum fire resistance rating. 

• Smoke walls extending from the corridor to the 

exterior walls were incomplete, with openings in 

the wall that would allow smoke to move from one 

side of the smoke wall to the other. 

 Depending on construction type and number of 

stories, sprinklers required throughout home. 

• Approximately 95 percent of the building was not 

protected by an automatic sprinkler system, even 

though the building construction type required 

complete sprinkler protection. 

Boston 

(Connecticut, 

Massachusetts, and 

New Hampshire) 

Depending on construction type and number of 

stories, sprinklers required throughout home. 

• Wood roof overhang used as a screened porch 

was not protected by sprinkler system. 

• Home failed to provide complete sprinkler 

protection for a three-story wood frame building. 

• Beauty salon closet was missing sprinkler. 

 Sprinkler system is operational and properly 

maintained. 

• Sprinkler in storage area was obstructed. 

 Doors are provided with latching devices, which 

will keep the doors tightly closed in their frames.

• Home failed to maintain corridor doors so that 

they closed tightly to resist the passage of smoke.

• Two resident room doors had obstructions that did 

not allow them to close completely. 

 Vertical openings or penetrations between 

floors are required to be protected (fire-rated 

and resistant to the passage of smoke). 

• Linen chute did not have a fire-resistance rating of 

at least 1 hour. 

 Fire drills are conducted quarterly on all shifts, 

and all staff are familiar with facility fire plan and 

appropriate procedures. 

• Home failed to conduct fire drill on third shift (from 

11 p.m. to 7 a.m. 

Chicago 

(Illinois, Michigan, 

Minnesota, Ohio, and 

Wisconsin) 

Depending on construction type and number of 

stories, sprinklers required throughout home. 

• Two exterior combustible canopies were not 

sprinklered. 

• Soiled-linen room in the basement contained 

unprotected steel framing for the floor above, 

which required the building to have complete 

sprinkler protection. 

 Sprinkler system is operational and properly 

maintained. 

• Home failed to properly maintain sprinkler system.

• Home did not replace six sprinklers on known 

recall list. 

 Hazardous areas have an approved fire 

extinguishing system or a 1-hour fire-rated 

construction. Doors shall be self-closing. 

• Hazardous area not separated with 1-hour firerated construction. 

• Employee lockers were not properly separated by 

a 1-hour fire-rated construction from the means of 

egress. 

• Mechanical room ceiling had a large opening and 

unprotected hole. 

Appendix II: Federal Comparative Survey 

Results for Fiscal Year 2003—Examples of 

Fire Safety Deficiencies Missed or Not Cited 
Appendix II: Federal Comparative Survey 

Results for Fiscal Year 2003—Examples of 

Fire Safety Deficiencies Missed or Not Cited 

Page 46 GAO-04-660 Nursing Home Fire Safety 

CMS regional office 

(state) Federal fire safety standard 

Fire safety deficiencies missed or not cited by 

state surveyors 

 Corridor walls must be fire-rated, extend from 

the floor to the roof deck or floor above, and 

resist the passage of smoke. In a fully 

sprinklered facility, corridor walls may terminate 

at the underside of the ceiling, need not be firerated, and must only resist the passage of 

smoke. 

• Smoke barrier above the ceiling at the corridor 

doors was open the entire width of corridor. 

 Doors are provided with latching devices, which 

will keep the doors tightly closed in their frames.

• Corridor doors separating the second floor dining 

room from the corridor had been removed. 

 Vertical openings or penetrations between 

floors are required to be protected (fire-rated 

and resistant to the passage of smoke). 

• Linen chute discharge door was not self-closing 

and remained open. 

Dallas 

(Louisiana and New Mexico) 

Corridor walls must be fire-rated, extend from 

the floor to the roof deck or floor above, and 

resist the passage of smoke. In a fully 

sprinklered facility, corridor walls may terminate 

at the underside of the ceiling, need not be firerated, and must only resist the passage of 

smoke. 

• Home failed to ensure that the corridor walls 

formed a smoke-tight barrier between the corridor 

and other areas of the facility. 

• Home failed to ensure that smoke barriers were 

maintained, which would ensure appropriate 

resistance to the passage of smoke by making 

penetrations smoke-tight. 

• Two separate holes in the smoke barrier were 

identified above the doors outside the staff 

conference room. 

• Home had a hole in the smoke barrier above the 

ceiling between the cardiac clinic equipment and 

the nursing home conference room. 

 Fire drills are conducted quarterly on all shifts, 

and all staff are familiar with facility fire plan and 

appropriate procedures. 

• Home failed to ensure that fire drills were carried 

out at least quarterly for day and evening shifts to 

ensure staff competence in the event of a fire. 

 Sprinkler system is operational and properly 

maintained. 

• Home failed to ensure that there were no 

obstructions to the water flow of installed 

sprinklers. 

• Home failed to ensure that replacement sprinklers 

and a wrench of appropriate size were available in 

the main sprinkler room. 

 HVAC system shall comply with fire safety 

standards and be installed in accordance with 

the manufacturer’s specifications. 

• Corridor was used as a part of the return air 

system, which would allow the spread of smoke to 

resident rooms during a fire. 

 Doors in fire separation walls, hazardous area 

enclosures, horizontal exits, or smoke partitions 

may be held open only by devices arranged to 

automatically close all such doors by zone or 

throughout the facility upon activation of fire 

detection systems. 

• One of the exit doors had panic hardware that did 

not permit the door to close to form a tight seal 

that would resist the passage of fire and smoke. 
Appendix II: Federal Comparative Survey 

Results for Fiscal Year 2003—Examples of 

Fire Safety Deficiencies Missed or Not Cited 

Page 47 GAO-04-660 Nursing Home Fire Safety 

CMS regional office 

(state) Federal fire safety standard 

Fire safety deficiencies missed or not cited by 

state surveyors 

Denver 

(Colorado, North Dakota, 

South Dakota, Utah, and 

Wyoming) 

Sprinkler system is operational and properly 

maintained. 

• Several sprinklers on known recall list were not 

replaced. 

• Four large coffee pots on the top shelf of the store 

room could obstruct the spray pattern of the 

adjacent sprinkler. 

• Two hoses from the floor-cleaning machine were 

hanging on the sprinkler piping in the basement 

housekeeping room. 

 Hazardous areas have an approved fire 

extinguishing system or a 1-hour fire-rated 

construction. Doors shall be self-closing. 

• Double doors to the clean linen side of the laundry 

and to the soiled-linen holding room were 

damaged and unable to resist the passage of 

smoke. 

• Boiler room doors to the corridor were missing 

self-closing devices. 

• Boiler room door was lacking a strike plate to 

complete the required latch. 

• Door to the clean linen room of the basement 

laundry was sagging so that it did not fit its frame. 

Also, the latch was not engaging its strike plate. 

 Corridor walls must be fire-rated, extend from 

the floor to the roof deck or floor above, and 

resist the passage of smoke. In a fully 

sprinklered facility, corridor walls may terminate 

at the underside of the ceiling, need not be firerated, and must only resist the passage of 

smoke. 

• Three pipes penetrated a wall with a 2-inch 

opening around the pipes. 

• There was an opening 1 inch in diameter larger 

than a pipe penetrating a smoke barrier. 

• Smoke barrier had open flutes above the wall and 

had an opening around two pipes 2 inches in 

diameter larger than the pipes. 

• Openings were observed that were approximately 

2 inches larger than the size of all 26 electrical 

conduits where they passed through the 

basement ceiling. 

• A TV lounge was not separated from the corridor 

with a smoke-resistant wall. 

 Doors are provided with latching devices, which 

will keep the doors tightly closed in their frames.

• Door to a conference room was held open with a 

wastebasket during the entire survey. 

• A resident room door had a piece of duct tape 

over the strike plate, which made the latch 

inoperative. 

• One resident room had no door latch and the 

roller latches for three resident rooms were not 

engaging their strike plates. 

• The door to the TV room did not close to a 

positive latch. 

• A resident room door was obstructed from closing 

due to a hook over the door holding a decoration. 
Appendix II: Federal Comparative Survey 

Results for Fiscal Year 2003—Examples of 

Fire Safety Deficiencies Missed or Not Cited 

Page 48 GAO-04-660 Nursing Home Fire Safety 

CMS regional office 

(state) Federal fire safety standard 

Fire safety deficiencies missed or not cited by 

state surveyors 

 Vertical openings or penetrations between 

floors are required to be protected (fire-rated 

and resistant to the passage of smoke). 

• Stair leading from the basement to the first floor 

did not have a fire-rated construction between it 

and the elevator equipment room. 

• A metal grate in the floor behind the walk-in 

freezer and cooler in the kitchen opened into a 

shaft located in the basement, consisting of 8-

inch-by-12-inch access holes. These access holes 

were not closed with a fire-rated material. 

• The door at the top of the basement stair did not 

have a self-closing device. 

• Basement stair door was missing its latch. 

• All three stairway doors were not at least 1-hour 

fire-rated. 

 Approved smoke detectors are installed, 

approved, maintained, inspected, and tested in 

accordance with the manufacturer’s 

specifications. 

• TV lounge did not have a smoke detection 

system. 

• Smoke detectors were located only on one side of 

all six smoke barrier doors. 

Philadelphia 

(Delaware and 

Pennsylvania) 

Hazardous areas have an approved fire 

extinguishing system or a 1-hour fire-rated 

construction. Doors shall be self-closing. 

• Soiled utility room had a door without a selfclosing mechanism. 

• Two soiled utility rooms had doors that were not 

self-closing. 

 Complete fire and smoke barriers required on 

each floor and between corridor and resident 

rooms. Doors are provided with latching 

devices, which will keep the doors tightly closed 

in their frames. 

• Wall separating personal care area and the 

nursing home had unsealed penetrations around 

pipes above the exit door. 

• A resident room door could not be closed and 

latched at all times. 

Source: GAO analysis of federal comparative and corresponding state surveys. 
Appendix III: Comments from the Centers for 

Medicare & Medicaid Services 

Page 49 GAO-04-660 Nursing Home Fire Safety 

Appendix III: Comments from the Centers for 

Medicare & Medicaid Services 
Appendix III: Comments from the Centers for 

Medicare & Medicaid Services 

Page 50 GAO-04-660 Nursing Home Fire Safety 
Appendix III: Comments from the Centers for 

Medicare & Medicaid Services 

Page 51 GAO-04-660 Nursing Home Fire Safety 
Appendix III: Comments from the Centers for 

Medicare & Medicaid Services 

Page 52 GAO-04-660 Nursing Home Fire Safety 
Appendix III: Comments from the Centers for 

Medicare & Medicaid Services 

Page 53 GAO-04-660 Nursing Home Fire Safety 
Appendix III: Comments from the Centers for 

Medicare & Medicaid Services 

Page 54 GAO-04-660 Nursing Home Fire Safety (290334) 
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