Linen Chute Door Latching Deficiency
Penalty
Summary
The facility failed to maintain the linen and trash chutes in accordance with NFPA 82 standards. Specifically, the self-closing device on the intake door to the linen chute did not latch when self-closed. This deficiency was observed during a Life Safety recertification survey on one of the three resident floors. The issue was identified during a tour of the linen chute room on the first floor, where it was noted that the intake door to the linen chute did not properly latch. The Director of Maintenance acknowledged the finding during an interview at the time of the survey.
Plan Of Correction
Plan of Correction: Approved May 2, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - The latches and pistons were replaced on all three laundry chute doors on 3/25/25 by the maintenance director. - A full house audit of laundry chutes will be completed and any negative findings will be immediately corrected. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - Maintenance staff will be re-educated on the maintenance requirements for rubbish chutes, incinerators, and laundry chutes NFPA 101 to meet code requirements. A record of education will be maintained for reference and validation. - All staff that routinely use the laundry chutes (nursing, dietary, maintenance, housekeeping) will be educated on the requirements that the linen chute door is required to latch when self-closed and to report negative findings to maintenance director/designee immediately. A record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance has created an audit tool to ensure that laundry chute doors are operational and that all chute doors close and latch. - The Director of Maintenance/designee will audit 2 x week for 4 weeks then weekly thereafter for 3 months. Negative findings will be corrected immediately and reported to the administrator. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.