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K0754
D

Improper Storage of Soiled Linen in Facility

Downingtown, Pennsylvania Survey Completed on 02-05-2025

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 failed to comply with NFPA 101 standards regarding the storage of soiled linen and trash containers. Specifically, the deficiency was observed in two of ten smoke compartments within the facility. On February 5, 2025, at 2:25 PM, soiled linen was found on the floor under the sink in the 300 Wing Tub Room. This observation was confirmed through an interview with the Director of Plant Operations, who acknowledged that the soiled linen was stored outside a rated room or container, which is a violation of the requirement that soiled linen or trash collection receptacles exceeding 32 gallons must be located in a protected space when not attended.

Plan Of Correction

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure no excess of receptacles are utilized. 1. The trash containers exceeding thirty-two gallons that were being utilized to store items have been removed and are no longer utilized in the facility and have been replaced with proper storage containers. The linen under the sink in three hundred wing tubs has been removed as well. 2. Facility wide inspection of any trash containers and under sink storage was completed on 2/7/2025. 3. Education with facility wide staff regarding improper disposal of soiled linen and containers needing to be under 32 gallons in shower and tub rooms, to be completed by 3/21/2025. 4. Weekly random audits to be completed for 12 months by Maintenance Director or designee for compliance. This information will then be entered on a log and will be presented to the QAPI meeting.

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