Failure to Obtain Required Approvals for Flood Remediation Projects
Penalty
Summary
The facility failed to maintain compliance with general requirements as outlined in NFPA 101, affecting two of three building levels. On November 14, 2024, observations revealed that the facility had not obtained the necessary approvals from the Department of Health State Plan Review and the Life Safety Division for several projects. Specifically, the first floor, north hall, had undergone remediation work due to recent flood damage, which required the evacuation and relocation of residents. Additionally, the ground floor, north hall, dementia unit, experienced total remediation of partitioning studs due to flood damage. Various rooms throughout the facility were also being used for item storage as a result of the flood event. During an onsite revisit survey on January 9, 2025, it was confirmed that the facility still had not obtained the required approvals for the aforementioned projects. The maintenance supervisor confirmed that the facility was in the process of preparing the necessary drawings and applications for submission. This ongoing deficiency highlights the facility's failure to secure the necessary approvals and occupancy grants from relevant authorities, as required by the Life Safety Code.
Plan Of Correction
The facility will not occupy the flooded areas. Cleanup and sanitation completed. Plans for rebuild on hold due to the pending change of facility ownership scheduled for 3/1/2025. A narrative and plans will be submitted for plan review prior to any work being conducted in the flooded areas. The facility is using designated storage areas for facility storage. Facility maintenance staff or designee will round daily to ensure the space remains safe and secure until rebuild is completed.