Deficiencies in Life Safety Drawings and Carbon Monoxide Alarm Protocols
Penalty
Summary
The facility failed to meet the minimum standards for operation as required by the Department and other state and local agencies. During a review of documentation and interviews conducted on February 4, 2025, it was found that the facility's life safety drawings were incomplete. Specifically, they lacked critical information such as resident room capacities, door swing designation, space/room designators, and highlighted rated assemblies. This deficiency was confirmed in an interview with the Acting Administrator and Director of Maintenance. Additionally, the facility did not have documentation of annual testing and inspection of installed Carbon Monoxide Alarms, as required by the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. The facility also could not verify that the installed carbon monoxide alarms were audible to on-duty staff, nor did it have documentation verifying evacuation and alarm protocols. These deficiencies were confirmed during interviews with the Acting Administrator and Director of Maintenance.
Plan Of Correction
Facility drawings will include resident room capacities, door swing designation, and space/room designators. Annual testing and inspection of installed carbon monoxide alarms will be completed. Carbon monoxide alarms will be placed where on-duty staff can hear the alarms. Facility staff will be educated on carbon monoxide alarms. Maintenance staff will be educated on the facility drawing. One carbon monoxide test will be completed monthly for 2 months. Audit results will be reviewed at the next QAPI meeting.