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K0211
C

Deficient Headroom in Basement Exit Corridor

Drums, Pennsylvania Survey Completed on 01-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have a deficiency in providing acceptable exits on one of its two levels. During an observation on January 22, 2025, at 11:45 a.m., it was noted that the basement-level exit access corridor, which is used exclusively by staff, did not meet the required headroom clearance of six feet eight inches. This was due to the presence of sprinkler piping and sprinkler heads that reduced the available headroom. The deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:30 p.m.

Plan Of Correction

1. The facility cannot retroactive more headroom in the basement. 2. The facility will submit for an FSES exemption. 3. The maintenance director was reeducated on headspace requirements and means of egress. 4. Random audits will be done to make sure nothing is stored or placed too close to ceilings. The results will be submitted to the QAPI committee for review and analysis of need of ongoing monitoring.

See complete original report
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