Failure to Obtain Approval for Room Use Changes
Penalty
Summary
The facility failed to maintain compliance with the general requirements of the life safety code, as evidenced by observations and interviews conducted during a survey. On December 18, 2024, it was observed that the basement floor seamstress room and mechanical equipment room had been converted into storage areas containing combustible materials. These rooms did not meet the hazardous area requirements, and the facility had changed the use of these rooms without obtaining the necessary approval from the State Plan Review and a granted occupancy from the Division of Life Safety. Interviews with the administrator and maintenance director confirmed that the required paperwork for the room change of use had not been submitted. Additionally, on the same day, it was observed that the facility had failed to obtain the required approval for changing the use of resident rooms to storage rooms on the fifth floor. This change also lacked the necessary approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division. During a revisit survey on February 5, 2025, it was determined that the facility had not submitted a narrative with plans to the Division of Safety Inspection Plan Review for these projects. Although a letter was provided indicating contact with the Division of Nursing Care Facilities regarding the fifth-floor storage, the notification for change of use or storage usage had not been submitted for approval. Interviews with the administrator and maintenance supervisor confirmed that the deficiencies were not completed at the time of the revisit survey.
Plan Of Correction
A plan review will be submitted to life safety on the website for a room change. Maintenance Director or designee will audit for appropriate storage in the basement area weekly x 4 weeks and monthly x 1 month. Results will be reviewed with the QA committee with monitoring if applicable.