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1001 PINE STREET

RENOVO, PA 17764

Building Construction Type and Height

Tag No.: K0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of one floor.

Findings include:

1. Observation on December 8, 2020, at 9:40 a.m., revealed the ceiling panel located within clean line required repair.

Exit interview with the facility administrator on December 8, 2020, between 10:35 a.m. and 10:45 a.m., confirmed the building construction deficiency.

Hazardous Areas - Enclosure

Tag No.: K0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of one floor.

Findings include:

1. Observation on December 8, 2020, at 9:55 a.m., revealed the medical records room door was held open by unapproved means (door chock).

Exit interview with the facility administrator on December 8, 2020, between 10:35 a.m. and 10:45 a.m., confirmed the hazardous area enclosure deficiency.

Sprinkler System - Maintenance and Testing

Tag No.: K0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of one floor

Findings include:

1. Observation on December 8, 2020, at 9:02 a.m., revealed the automatic sprinkler gauges were overdue for replacement, or recalibration (12/2014).

Exit interview with the facility administrator on December 8, 2020, between 10:35 a.m. and 10:45 a.m., confirmed the automatic sprinkler system deficiency.

Corridor - Doors

Tag No.: K0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of one floor.

Findings include:

1. Observation on December 8, 2020, at 9:15 a.m., revealed the resident room 218 door was not smoke-tight.

Exit interview with the facility administrator on December 8, 2020, between 10:35 a.m. and 10:45 a.m., confirmed the corridor opening deficiency.

Gas Equipment - Cylinder and Container Storag

Tag No.: K0923

Based on observation and interview, it was determined the facility failed to maintain cylinder storage in one location, affecting one of one floor.

Findings include:

1. Observation on December 8, 2020, at 9:33 a.m., revealed an unsecured oxygen tank was located within the oxygen storage room.

Exit interview with the facility administrator on December 8, 2020, between 10:35 a.m. and 10:45 a.m., confirmed the oxygen cylinder storage deficiency.