Failure to Notify Department and Maintain Required Safety Documentation
Penalty
Summary
The facility failed to notify the Pennsylvania Department of Health prior to initiating external window renovations throughout the building and additional interior renovations to a shut down wing on the ground floor following water damage. This action was taken without obtaining Department-approved plans, as confirmed by the Maintenance Supervisor and Director of Safety/Security during the exit interview. The lack of notification and approval was determined through observation, document review, and staff interviews. Additionally, the facility did not provide portable Life Safety Code Floor Plans that included required information such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. During the survey, it was also found that the facility lacked a carbon monoxide alarm evacuation policy plan and had not conducted associated staff in-service training, as required by the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. These deficiencies affected the entire facility and were confirmed by facility leadership during the exit interview.
Plan Of Correction
Approval for window renovation received from DSI on 5/15/25. Facility will ensure that approval is obtained prior to beginning any future renovations. Facility will ensure that floor plans are readily available for future surveys. Carbon monoxide policy in place. Staff will be educated on carbon monoxide policy.