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K0541
E

Failure to Maintain Fire Resistance of Linen Chutes

Stillwater, Pennsylvania Survey Completed on 12-23-2024

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 fire resistance rating of linen chutes and discharge rooms, affecting two of four levels. During an observation on December 23, 2024, between 11:45 a.m. and 12:05 p.m., it was noted that the linen chute doors on the third and second floors of the South Wing did not close and latch properly when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.

Plan Of Correction

1. On 1/3/2025 the Maintenance team replaced the existing hardware on the 2nd and 3rd floor South Wing linen chutes. 2. On 12/23/24 the Maintenance Director inspected the linen chutes on the other units and verified the proper functionality. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining the fire resistance rating of the linen chutes in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify positive latching and the proper functionality of the linen chute doors. Results of the audits will be reviewed at the QAPI meeting held monthly.

See complete original report
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