Overview
- Fire Chief Jeffrey P. Bacon’s after-action report recommends applying nursing-home fire standards to assisted living, group homes, boarding houses, day cares, sober homes, and shelters statewide.
- The report credits first responders with rescuing 53 residents in extreme conditions and notes 33 firefighters arrived within 15 minutes versus a national benchmark of 42 within 10 minutes.
- Investigators continue to treat the fire as accidental, focusing on a second-floor room with a medical oxygen device and smoking materials, with officials saying oxygen worsened the spread.
- Structural problems—no hallway fire doors or smoke compartmentalization, window AC units secured with plywood, and an elevator area involved in the fire—forced many rescues through small bathroom windows.
- Recommendations include increased staffing, radio-only incident communications, targeted rescue drills for upper floors and confined openings, added support equipment and mutual aid planning, expanded state-level life-safety inspections, and continued legal and inspection follow-up as lawsuits proceed.