Linen Chute Door Fails to Latch Properly
Penalty
Summary
The facility failed to maintain the trash chutes in accordance with NFPA 82 standards. During a Life Safety recertification survey, it was observed that the intake door to the linen chute on the second floor of the southwest unit did not positive latch when tested to self-close. This deficiency was noted on one of the two resident floors in the nursing home. A maintenance staff member confirmed the issue during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance staff repaired the identified linen chute intake door on South West 2 second floor unit. The trash chute intake door self-closes and positive latches. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all intake chute doors throughout the facility for same deficiency. No other deficiencies were found. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All maintenance staff will receive additional education and all participants will understand the life safety issues with chute intake doors must self-close and positive latch in accordance with the requirements of NFPA 82. The In-Service Coordinator has been assigned the responsibility for the education of staff. This education will also be provided to all new Maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all chute intake doors monthly and utilize an audit tool to document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted.