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K0225
E

Stair Tower Enclosure Deficiency

Williamsport, Pennsylvania Survey Completed on 12-30-2024

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 the exit stair tower enclosure, affecting all three floors. During an observation on December 30, 2024, at 10:40 a.m., it was noted that the fire exit hardware on the first floor's west stair tower enclosure exit discharge door was missing an end cap. This deficiency was confirmed during an exit interview with the Facility Administrator later that morning.

Plan Of Correction

1. Missing end cap on the first floor west stair tower door was replaced. 2. Other stair tower door enclosures will be checked for missing end caps. 3. Maintenance will be re-educated on ensuring that door enclosures have end caps installed. 4. Maintenance Director/ designee will conduct random audits to verify that exit hardware end caps are in place weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.

See complete original report
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