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K0211
E

Failure to Maintain Egress Door Signage for Special Locking Arrangements

Carlisle, Pennsylvania Survey Completed on 12-03-2024

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 failed to maintain proper egress door signage for special locking arrangements, which affected multiple smoke compartments within the building. During an observation on December 3, 2024, it was noted that the exit discharge doors were equipped with special locking arrangements but lacked the required delayed egress signage. This deficiency was observed in one of four smoke compartments, specifically at the Service Corridor double doors. Further observations on the same day revealed similar issues in three additional smoke compartments. The exit discharge doors on the 1st floor, including the Therapy Hall by Therapy, Hall 3 by Resident Room 48, and Hall 4, were all found to be lacking the necessary signage for their special locking arrangements. These findings were confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of the required signage.

Plan Of Correction

Signage will be purchased and installed on egress doors. Signs will be installed by 1/13/25. Signage will be inspected every month by the Director of Environmental Services or designee to ensure that they are in place and in good condition. This inspection will be added to our preventative maintenance program to ensure signage is in place and in good condition. The results of this will be reported by the Director of Environmental Services or designee to the Quality Assurance and Performance Improvement Committee. Signage will be purchased and installed on egress doors. Signs will be installed by 1/13/25. Signage will be inspected every month by the Director of Environmental Services or designee to ensure that they are in place and in good condition. This inspection will be added to our preventative maintenance program to ensure signage is in place and in good condition. The results of this will be reported by the Director of Environmental Services or designee to the Quality Assurance and Performance Improvement Committee.

See complete original report
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