The facility failed to keep the main kitchen stove/oven in working order, resulting in altered meal preparation for residents over an extended period. During a lunchtime observation, the stove/oven was found nonfunctional and staff were serving cold ham and cheese sandwiches instead of hot meals. The cook stated the stove/oven had been out of service for over 2 months and that the menu had been changed for more than a month, causing resident dissatisfaction. The Dietary Manager and the Nursing Home Administrator both confirmed that the stove/oven had been down for over a month and described unsuccessful attempts to replace it due to incompatible gas and electrical hookups.
The facility failed to ensure that the East Hall crash cart was maintained in safe operating condition. Surveyors observed two expired ambu bags and masks in the cart, even though weekly crash cart checks were required on the checklist. The DON confirmed the expired equipment and the failure to ensure the cart was ready for use.
Surveyors found that the main kitchen’s low-temp chemical dish machine was not functioning properly, as repeated testing with chemical strips after multiple runs showed sanitizer levels below 10 ppm instead of the required 50–100 ppm. A dietary manager confirmed that the facility failed to ensure the dish machine was in proper working order.
Beds for multiple residents were observed to move freely even when locked. One resident was cognitively intact and dependent on staff for daily care, another was cognitively intact and needed moderate assistance with bed mobility and transfers, and a third resident’s bed also failed to lock securely. Staff knew at least some of the beds were not locking fully, but the issue was not reported to maintenance, and the LPN did not verify whether the wheels were actually securing.
The facility failed to keep its dish machine in safe working order, resulting in staff manually pushing dishware through a machine with a broken conveyor belt and missing curtains and jet caps. The Dietary Director reported the malfunction and requested repair approval from the Administrator, who approved the request, but the machine remained in disrepair while quotes for repair and replacement were obtained over several weeks.
Expired supplies were found on the Fourth Floor crash cart and AED, including oxygen masks, a tracheostomy kit, Ambu bags, and AED pads. Facility documentation showed no monitoring of the AED, and an RN stated the crash cart and AED should be checked daily but confirmed that no one was monitoring the AED function or the expired items.
Surveyors found that the main kitchen’s low-temperature dish machine had non-functioning wash and rinse temperature gauges, and a dietary employee reported that the gauges had not worked consistently since installation. The Nursing Home Administrator confirmed that the facility failed to keep this essential equipment in proper working order, resulting in a deficiency related to the Administrator’s responsibility.
Surveyors found that essential mechanical equipment was not maintained in safe, working order. In the kitchen, the ventilation system above the dishwasher had a broken, non-functioning fan that had been inoperable for several weeks, and no measures were implemented to prevent the compromised ventilation from affecting food contact surfaces. In the back hall elevator, the ventilation fan was broken with dust accumulation inside the elevator, the bottom side panel wall was cracked, and the door tracks contained dirt and debris, all indicating inadequate maintenance of critical equipment.
The facility did not follow its freezer maintenance policy requiring regular cleaning and removal of excess ice in the main kitchen walk-in freezer. Surveyors observed heavy ice accumulation on the ceiling extending from the condenser, on the floor near the entrance, and on frozen food boxes on top shelves, with the condenser coils encased in ice. The Dietary Manager confirmed these conditions and acknowledged that the ice should be removed.
Surveyors found that two crash carts lacked multiple required emergency items, including code books, ambu-bags, suction kits, PPE, alcohol-based hand rub, and in one case a blood pressure cuff, stethoscope, glucometer, and full oxygen tanks, with incomplete and unsigned daily checklists. At the same time, both facility dryers were inoperable, forcing staff to rely on a small non-commercial dryer and resulting in extensive backlogs of soiled linen and widespread shortages of clean towels and washcloths on multiple halls. Staff reported difficulty bathing residents, described using cut-up bath blankets, dry wipes, baby wipes purchased personally, and clothing protectors in place of standard linen, and leadership confirmed the failures to maintain the crash carts and dryers in safe operating condition.
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