Failure to Obtain Approval for Room Use Changes
Penalty
Summary
The facility failed to maintain general requirements of the life safety code on two of six building levels. On December 18, 2024, it was observed that the basement floor seamstress room and mechanical equipment room were converted to storage locations containing combustible materials, which do not meet hazardous area requirements. The facility 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. Additionally, the facility did not obtain the required approval for changing the use of resident rooms to storage rooms on the fifth floor. Interviews with the administrator and maintenance director confirmed that the facility did not submit the required paperwork for these room changes.
Plan Of Correction
1. Maintenance Director immediately removed combustible materials from the basement area. 2. The approval of the state plan review with granted occupancy that was granted on 8/13/24 from the Life Safety Division will be placed in the Emergency Preparedness Binder. An additional request for approval for the change of use of the 5th floor will be submitted to plan review requesting the occupancy change. 3. Maintenance Director or designee will audit for appropriate storage in the basement area weekly x 4 weeks and monthly x 1 month. 4. Results will be discussed with QA committee with monitoring if applicable.