Fire Protection Deficiencies in Linen Chutes
Summary
The facility failed to maintain the fire protection rating for linen chutes, as evidenced by several deficiencies observed during a survey. On multiple floors, including the second, third, fourth, seventh, eighth, and tenth, the rubbish and laundry chute doors in the soiled utility rooms were found to be non-compliant. Specifically, the chute doors on the second and third floors failed to positively latch, while the chute door on the fourth floor was propped open by a lining cart. Additionally, the chute doors on the seventh, eighth, and tenth floors failed to close and latch properly. These deficiencies were confirmed during an exit interview with the Maintenance Director, who acknowledged the issues with the chute doors. The failure to maintain the fire protection rating for these chutes affects six out of fifteen levels in the facility, indicating a significant lapse in maintaining fire safety standards as required by NFPA 101. The report does not mention any corrective actions or plans to address these deficiencies.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0541-a Door was repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-b Door was repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-c Linen chute door was closed and Facility staff will be educated about the hazards of propping doors open. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-d Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-e Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-f Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Penalty
The facility did not maintain the fire resistance of its trash chutes, affecting one level. An observation revealed that the trash chute door on the second floor failed to close and latch, which was confirmed by the Maintenance Director.
The facility did not maintain the fire protection rating for linen chutes, affecting one level. The chute door in the first-floor soiled utility room failed to self-close because it was wedged into the drywall when fully opened. This issue was confirmed by the Administrator and Maintenance Director.
The facility did not maintain the fire resistance rating of its rubbish chutes, as observed when the rubbish chute door on the second floor Skilled Nursing Trash Room failed to self-close and latch. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the soiled linen and rubbish chutes as the 1st floor laundry chute door did not latch properly, affecting three of four floors. This was confirmed during an interview with the facility administrator.
The facility did not maintain the fire protection rating for linen chutes, affecting the entire facility. Observations revealed that the soiled utility room chute doors on multiple floors failed to self-close and positively latch, as confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the fire resistance rating of its trash chute system on the second floor. The trash chute door did not close and latch properly when tested, as confirmed by the Executive Director of Construction and Ancillary Services.
Trash Chute Door Fails to Close and Latch
Penalty
Summary
The facility failed to maintain the fire resistance of its trash chutes, specifically affecting one of the three levels in the facility. During an observation on May 1, 2025, at 9:55 a.m., it was noted that the trash chute door on the second floor did not close and latch as required. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
On the second floor, the trash chute door was fixed and is able to close and latch. It was clean and clear of debris. Staff in-serviced on the importance to keep it clean and free from debris. The Director of Maintenance or designee will audit trash chute 3x weekly for x2 monthly. All findings will be brought to QAPI for review.
Failure to Maintain Fire Protection Rating for Linen Chutes
Penalty
Summary
The facility failed to maintain the fire protection rating for linen chutes, specifically affecting one of the four levels. During an observation on April 28, 2025, at 9:35 a.m., it was noted that the chute door in the soiled utility room on the first floor did not self-close as required. This failure was due to the door being wedged into the drywall when fully opened. An interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day confirmed the issue with the chute door not self-closing.
Plan Of Correction
A wall stop was placed to ensure the soiled utility room chute door can self-close. The Director of Facilities/Designee will perform random monthly audits times 4 then quarterly audits to ensure all utility room chute doors self-close. The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.
Failure to Maintain Fire Resistance of Rubbish Chute
Penalty
Summary
The facility failed to maintain the fire resistance rating of its rubbish chutes and discharge rooms, specifically affecting one of the three levels. During an observation on April 7, 2025, at 1:10 p.m., it was noted that the rubbish chute door on the second floor Skilled Nursing Trash Room did not self-close and latch when tested. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Maintenance staff repaired the rubbish shoot door in the second floor Skilled Nursing trash room to ensure it self-closes and latches when tested. Maintenance staff will audit the rubbish shoot door monthly to ensure proper functioning and report findings to the Quality Council to ensure compliance.
Failure to Maintain Laundry Chute Door Latching Mechanism
Penalty
Summary
The facility failed to maintain the soiled linen and rubbish chutes in compliance with NFPA 101 standards. During an observation on January 29, 2025, at 10:27 am, it was noted that the discharge laundry chute door on the 1st floor did not latch into the frame when tested. This issue affected three of the four floors in the facility. The deficiency was confirmed during an interview with the facility administrator at the time of the exit conference on the same day at 11:00 am.
Plan Of Correction
The laundry chute was repaired on 2/5/2025. Maintenance director/designee completed an audit to verify facility chutes function properly. Maintenance Director was educated on maintaining laundry chute latch by NHA. Maintenance director/designee will audit facility chutes to verify latching weekly x4 and monthly x3 and report findings to monthly QAPI committee.
Failure to Maintain Fire Protection Rating for Linen Chutes
Penalty
Summary
The facility failed to maintain the fire protection rating for linen chutes, which affected the entire facility. During observations conducted on January 27, 2025, between 12:00 p.m. and 2:30 p.m., it was noted that the soiled utility room chute doors on the first, second, and third floors did not self-close and positively latch as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 2:30 p.m. on the same day.
Plan Of Correction
1. The chute doors were immediately repaired to ensure they are in proper working order. 2. Chute doors were audited to ensure they remain in proper working order. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of chute doors will be conducted to ensure they remain in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Trash Chute Door Fails to Close and Latch
Penalty
Summary
The facility failed to maintain the fire resistance rating of its trash chute system, specifically on the second floor. During an observation on January 21, 2025, at 12:20 p.m., it was noted that the trash chute door did not close and latch properly when tested. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services at 1:15 p.m. on the same day.
Plan Of Correction
- ED of construction to Inservice supervisor of Plant Operations on policy and procedures for trash, laundry chutes. - Trash chute replaced. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to ensure compliance of chute doors policy and procedure. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
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