K0111 ? K111: Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

F

Facility Non-Compliance with Building Rehabilitation Standards

Clepper ManorSharon, Pennsylvania Survey Completed on 04-08-2025

Summary

The facility failed to comply with building rehabilitation requirements as evidenced by several projects completed without submitting plans to the State Plan Review or obtaining a granted occupancy from the Division of Safety Inspection. On April 8, 2025, during an observation between 8:45 a.m. and 11:00 a.m., it was noted that an outside generator was installed in November 2023 without the necessary plans or an H number. Additionally, the fire alarm panel was replaced, and the automatic fire detection system and sprinkler head were removed from the elevator pit.

An interview with the maintenance director on the same day confirmed that the facility was unable to provide the required plans documentation at the time of the survey. These actions indicate a failure to adhere to the NFPA 101 Building Rehabilitation standards, specifically regarding repair, renovation, modification, or reconstruction requirements, as well as the necessary compliance for changes in use or occupancy and additions.

Plan Of Correction

Maintenance director and administrator will obtain the appropriate plans and H number for the outside generator installation from the contractor and submit to the state by 5/13/2025.

Maintenance director and administrator will obtain plans for the fire alarm panel that was replaced from the contractor and submit to the state by 5/13/2025.

Maintenance director and administrator will obtain the appropriate plans and H number for the outside generator installation from the contractor and submit to the state by 5/13/2025.

Maintenance director and administrator will obtain plans for the fire alarm panel that was replaced from the contractor and submit to the state by 5/13/2025.

Penalty

No penalty information released