Non-compliance with Soiled Linen and Trash Container Capacity
Summary
The facility failed to comply with NFPA 101 standards regarding the capacity of soiled linen and trash containers. On December 11, 2024, an observation revealed that the accumulated trash and soiled-linen containers exceeded the allowed 32 gallons in a 64-square foot area in the 3rd floor Central Bath, near Resident Room 307. This was confirmed through an interview with the Director of Maintenance. A follow-up observation on February 7, 2025, confirmed that the issue had not been corrected, as verified by an interview with Maintenance Man 1.
Plan Of Correction
Maintenance removed all observed accumulated trash and soiled linen containers in the 3rd floor central bath by resident room 307. Maintenance Director or Designee will re-educate employees on the importance of not placing containers greater than 32 gallons in a 64-square foot area. Maintenance Director or Designee & DON or Designee will complete weekly random audits of the bath areas to ensure there are no trash or soiled linen containers in this area. Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.
Penalty
The facility failed to comply with NFPA 101 standards by storing three 96-gallon shredder containers in a non-rated ground floor lobby. The containers exceeded the 32-gallon limit for unattended storage without a 1-hour fire-rated protection. The Director of Maintenance confirmed the non-compliance.
The facility did not adhere to NFPA 101 standards by storing soiled-linen and trash containers exceeding 32 gallons in the 1st floor corridor outside a resident's room, rather than in a 1-hour fire-rated room. This was confirmed by the Director of Maintenance.
The facility was found to be non-compliant with NFPA 101 standards as soiled linen was improperly stored on the floor under the sink in the 300 Wing Tub Room, outside a rated room or container. This was confirmed by the Director of Plant Operations.
The facility failed to comply with NFPA 101 standards by allowing accumulated trash and soiled-linen containers to reach 32 gallons in a 64-square foot area on the 3rd floor Central Bath, near a resident room. This was outside a protected area, violating the requirement for such containers to be within a protected hazardous area if exceeding the specified capacity. The Director of Maintenance confirmed the oversight.
Non-compliance with NFPA 101 for Trash Container Storage
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards regarding the storage of soiled linen and trash containers. During an observation on April 15, 2025, at 1:35 PM, it was noted that three 96-gallon shredder containers were stored in the ground floor lobby. This area did not have a 1-hour fire-rated protection, which is required for storing containers exceeding 32 gallons when not attended. The Director of Maintenance confirmed that the containers were not stored in a rated assembly, leading to the deficiency.
Plan Of Correction
The three 96-gallon shredder containers were moved to an area with 1 hour protected rating. Maintenance staff was educated a 1-hour protected rating space is required for storage of soiled-linen and trash containers exceeding 32 gallons. Director of Plant Operations or designee will audit 1 time a week for a month; if compliance is achieved; then random audits monthly of soiled-linen and trash containers exceeding 32 gallons are stored in a 1-hour protected space. Audit results will be reported at QAPI.
Improper Storage of Soiled-Linen and Trash Containers
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the storage of soiled-linen and trash containers. During an observation on March 31, 2025, at 12:50 PM, it was noted that soiled-linen and trash containers exceeding 32 gallons were stored in the 1st floor corridor outside Resident Room 221. These containers were not placed in a 1-hour fire-rated room as required. An interview with the Director of Maintenance at the same time confirmed that the containers were not stored in a rated assembly, indicating a lapse in adherence to safety protocols for hazardous areas.
Plan Of Correction
1. The soiled linen and trash containers were removed from outside resident room 221. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct audits of the 1st and 2nd floor corridors for soiled linen and trash containers daily until compliance is achieved, then weekly on all 3 shifts x 4 and then randomly for 2 months. 4. Findings of Audits will be submitted to QAPI for review.
Improper Storage of Soiled Linen in Facility
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the storage of soiled linen and trash containers. Specifically, the deficiency was observed in two of ten smoke compartments within the facility. On February 5, 2025, at 2:25 PM, soiled linen was found on the floor under the sink in the 300 Wing Tub Room. This observation was confirmed through an interview with the Director of Plant Operations, who acknowledged that the soiled linen was stored outside a rated room or container, which is a violation of the requirement that soiled linen or trash collection receptacles exceeding 32 gallons must be located in a protected space when not attended.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure no excess of receptacles are utilized. 1. The trash containers exceeding thirty-two gallons that were being utilized to store items have been removed and are no longer utilized in the facility and have been replaced with proper storage containers. The linen under the sink in three hundred wing tubs has been removed as well. 2. Facility wide inspection of any trash containers and under sink storage was completed on 2/7/2025. 3. Education with facility wide staff regarding improper disposal of soiled linen and containers needing to be under 32 gallons in shower and tub rooms, to be completed by 3/21/2025. 4. Weekly random audits to be completed for 12 months by Maintenance Director or designee for compliance. This information will then be entered on a log and will be presented to the QAPI meeting.
Non-compliance with Soiled Linen and Trash Container Standards
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards regarding the management of soiled linen and trash containers. During an observation on December 11, 2024, at 12:45 PM, it was noted that the facility had accumulated trash and soiled-linen containers totaling 32 gallons within a 64-square foot area on the 3rd floor Central Bath, near Resident Room 307. This accumulation was outside of a protected area, which is a violation of the requirement that such containers should not exceed 32 gallons in a 64-square foot area unless located in a room protected as a hazardous area. The Director of Maintenance confirmed the facility's failure to monitor and manage the amount of trash and soiled-linen containers appropriately.
Plan Of Correction
Maintenance removed all observed accumulated trash and soiled linen containers in the 3rd floor central bath. Maintenance Director or Designee will re-educate employees on the importance of not placing containers greater than 32 gallons in a 64-square foot area. Maintenance Director or Designee will complete weekly random audits of the bath areas to ensure there are no trash or solid linen containers in this area. Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.
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