Failure to Obtain Required Approvals and Maintain Accurate Life Safety Floor Plans
Penalty
Summary
The facility failed to maintain compliance with general requirements of the Life Safety Code (LSC) on one of its six building levels. Specifically, the facility did not obtain the required approval from the Department of Health State Plan Review or a granted occupancy from the Life Safety Division for converting resident rooms to storage rooms on the fifth floor. This deficiency was observed during a site visit and is a repeat finding from the previous year's survey. Additionally, the facility was unable to provide accurate floor plans that identified the fifth floor rooms as storage locations, and both the administrator and maintenance director confirmed that the necessary paperwork had not been submitted. Further deficiencies were identified regarding the facility's failure to maintain and provide accurate, portable floor plans that outlined designated rated partitions throughout the building. During document review and interviews, it was found that the facility did not have a Life Safety Code Floor Plan on-site that included required elements such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. The maintenance supervisor confirmed that the floor plan provided during the survey did not accurately contain these required items.
Plan Of Correction
The systematic change will be to get a copy of portable floor plans for the facility. A copy will be kept in the Administrator's office and the Director of Maintenance's office. The Administrator will review annually portable copies with the Director of Maintenance to assure there's a complete set for use. Monthly Quality Assurance meetings will review floor plans.