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Tens of thousands of the country's most vulnerable people are living in nursing homes without adequate sprinklers or that are missing them altogether, according to government data.
Despite a history of deadly nursing home fires and a five-year lead-up to an August 2013 deadline to install sprinklers, 385 facilities in 39 states fail to meet requirements set by the Centers for Medicare and Medicaid Services, the federal agency whose duties include regulating nursing homes. Together, those facilities are licensed to house more than 52,000 people, according to data from the agency known as CMS.
Forty-four of the homes have no sprinklers at all.
"That is intolerable in this day and age," said Brian Lee, executive director of Families for Better Care, which advocates for nursing home residents. "It's not like they don't have money to put these systems in. They have the money. They just choose not to do so."
CMS, which had warned last year it would not grant extensions to the sprinkler rules, said 97 percent of facilities meet requirements, which are basic fire-safety tools in many structures, but especially important in nursing homes where residents may be unable to quickly evacuate.
"CMS and states are actively engaging with the rest of the facilities to verify their compliance with this regulation and will take appropriate actions for noncompliance to ensure the safety of residents," the agency said in a statement to The Associated Press.
There have been numerous deadly nursing home fires over the past century, but it wasn't until 2003 that CMS has required sprinklers in newly constructed facilities. That year, two blazes at Greenwood Health Center in Hartford, Connecticut, where 16 people were killed, and NHC Healthcare Center in Nashville, Tennessee, where 15 were killed refocused attention on fire safety in nursing homes. Neither of those buildings had automatic sprinkler systems, raising the issue of whether federal rules should require that older facilities be retrofitted.
Five years later, in 2008, CMS did issue that requirement, giving homes another five years to comply.
States have sometimes strengthened their own fire-safety laws, particularly if they experienced a nursing home tragedy, as Tennessee did after the Nashville fire. No Tennessee homes show up on the CMS list of offenders.
David Randolph Smith, an attorney who represented the families of numerous victims in the NHC blaze, said he took for granted that facilities around the country were also in compliance.
"That's really quite shocking," he said. "Lots of things catch on fire in these buildings. Some of them are so old that they have polyurethane insulation. They're tinder boxes in many cases."
However, there has been progress since December, when CMS said 714 homes were not in compliance. An analysis of ownership data shows there are currently 204 for-profit facilities failing to meet sprinkler rules; 145 nonprofits; and 36 run by local and state governments.
Sprinkler costs in nursing homes vary widely. After the 2003 Greenwood fire, officials in Connecticut estimated the average cost of upgrading facilities that were partially equipped with sprinklers at $270,000. The average for nursing homes with no system in place was $363,000.
In older buildings it can be a more complicated job, which could include cutting through walls, dealing with asbestos-encased pipes and managing original layouts not designed for such modifications. Tom Burke, a spokesman for the American Health Care Association, which represents nursing homes, said though some facilities may have encountered physical barriers to installing sprinklers, across the larger industry fire-safety measures have been "steadfastly supported" and adequate sprinklers have been installed.
"Its value as a safety and patient safety feature is undisputed," he said.
Some facilities on the list of noncompliant homes say they have met the requirements and weren't sure why they were cited. CMS said the list was accurate as of July, but some facilities may not have been surveyed since meeting compliance. Surveys generally happen annually, so facilities that have added sprinklers could still be on the list if the modifications weren't completed before their last inspection.
For those who remain out of compliance, CMS said it could take a variety of enforcement actions, including denying payment and terminating a facility's provider agreement. A small number of the noncompliant facilities may be granted extensions for extenuating circumstances, such as if they are building a replacement to their current structure or undergoing major renovations.
A 2004 Government Accountability Office report noted no facility fully equipped with sprinklers had ever had a multiple-casualty fire. Still, focused on medical care and other daily concerns, many incoming residents and their families never give it any thought.
June Liccione, of New Rochelle, New York, oversaw her mother's care before her death several years ago. She went in and out of nursing homes as her health declined due to diabetes. At least two of the homes she resided in are among those not meeting sprinkler rules, but Liccione said she was so worried about her mother being fed, properly medicated and getting the care of good nurses, she didn't even think about it.
"There were so many other things to worry about," she said, "I didn't worry about a fire."