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K0541
F

Failure to Maintain Fire Protection Rating for Linen Chutes

Wyndmoor, Pennsylvania Survey Completed on 01-27-2025

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 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.

See complete original report
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