Failure to Maintain Ice Machine and Provide Ice for Residents
Summary
The deficiency involves the facility’s failure to maintain essential equipment in safe operating condition when the only ice machine malfunctioned and residents were left without ice for two consecutive days. Staff interviews and observations on 3/23/26 confirmed that the ice machine stopped dispensing ice on Friday 3/20/26 and that no ice was available for residents on 3/21/26 and 3/22/26. The facility’s own policy stated that ice machines and ice storage/distribution containers would be used and maintained to assure a safe and sanitary supply of ice, and the manufacturer’s guidelines specified that equipment should not be operated when damaged or not in original manufactured condition. Despite these requirements, the ice chute/dispenser on the aging ice machine repeatedly came off track, preventing ice from being dispensed, and no alternative ice supply was provided over the weekend. Two cognitively intact residents reported not having ice and described how this affected their fluid intake. One resident with an indwelling catheter, neuromuscular dysfunction of the bladder, pressure ulcer, protein-calorie malnutrition, and paraplegia stated she had not received any ice since Friday and that she preferred ice-cold drinks; her cup was observed to be empty, and she reported she did not consume as much fluid as usual because there was no ice. Her roommate, who had diagnoses including cerebral palsy, malignant neoplasm of the breast, and bipolar disorder, also reported there was no ice to drink over the weekend, stated she had a recent UTI and needed to drink fluids to help prevent another infection, and requested a soda with ice when ice finally became available. Both residents’ MDS assessments showed BIMS scores in the cognitively intact range. Multiple staff members confirmed the lack of ice and described the usual process and the breakdown in communication and follow-up. CNAs reported there was no ice over the weekend, that residents complained about the lack of ice, and that ice was normally kept in chests at the nurses’ station and changed once per shift. An LVN stated there was no ice available when she passed medications on Saturday and emphasized that some residents would not drink as much fluid if it was not cold. Dietary staff, including the Certified Dietary Manager and cooks, stated the ice machine dispenser had come off track, that there was no ice in the kitchen freezers, and that no one contacted dietary leadership over the weekend. The Director of Maintenance acknowledged the ice machine was old and had acted up off and on, that he had previously realigned the dispenser on 3/19/26, and that he received a text on 3/20/26 about the machine not working but assumed the issue was resolved because he received no further communication. The Administrator, DON, MDS Coordinator, and payroll staff each reported they were not effectively notified or did not follow up after receiving notice, resulting in residents having no access to ice for two days and the facility failing to maintain the ice machine in safe operating condition. The facility’s own documentation from 3/19/26 noted that the ice chute had fallen off track, likely due to pushing too hard on the lever, and the manufacturer’s manual described that ice falls from the paddle wheel to the ice chute opening of the dispenser bin and that damaged or altered equipment should not be operated. Despite this known, recurring problem with the dispenser coming off track, the ice machine remained the sole source of ice, and no interim measures were implemented when it failed again over the weekend. Staff interviews, resident statements, and record review collectively demonstrate that the facility did not ensure continuous availability of ice or timely repair/alternative provision when the ice machine malfunctioned, creating a lapse in maintaining essential equipment in safe operating condition as required by facility policy and manufacturer guidelines.
Penalty
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Surveyors found that the crash cart contained multiple expired or out-of-date emergency supplies, including a suction machine overdue for inspection, expired iodine packets, aspirin, a biohazard spill kit, airway tubes, suction components, small bore extension kits, a central line dressing kit, and a heat pack. The DON confirmed the items were expired but reported believing the dates were manufacturing dates and stated that monthly checks of the crash cart were performed using a checklist that did not record expiration dates. Review of facility documentation showed completed checklists with all items marked as present but no tracking of expirations, and an office manager confirmed there was no active crash cart policy in place, despite an undated written policy stating that crash carts would be kept in a constant state of readiness and that expiration dates would be routinely monitored.
The facility failed to maintain a functional phone system on its secured behavioral units. On the women’s secured behavioral unit, the nurse’s station phone was not working and a second unit phone was unplugged, leaving staff without a working line for incoming calls from families. On the men’s secured behavioral unit, the unit phone was also unplugged and not operational, and staff reported frequent problems with phones not working. The receptionist stated that after her work hours, calls are routed to nurse’s stations, but acknowledged there had been recent periods when phones were not working. The administrator did not view families’ inability to call in as a problem, noted that staff sometimes shared personal phone numbers with families, and confirmed there was no specific phone policy.
The facility did not maintain its dishwasher in working order over multiple extended periods, as documented in temperature logs and confirmed by staff interviews and surveyor observations. Due to recurring mechanical and chemical-dispensing problems, the dishwasher was frequently out of service, and technicians were repeatedly called for repairs. As a result, all meals were served in disposable Styrofoam containers with plastic utensils, and a resident reported difficulty cutting food and cutting through the container while eating. These conditions were inconsistent with the facility’s sanitization policy requiring equipment to be kept in good repair.
Surveyors found that essential kitchen equipment was not kept in safe, working order. A high-temperature dishwasher was observed leaking significantly, with water running down a wall near electrical outlets and pooling on the floor where staff stood while operating it, despite multiple critical work orders being marked as completed and staff reporting the leak had persisted for weeks. In addition, a commercial food processor used for pureed foods was missing a key cover component, leading staff to improvise with aluminum foil, which allowed soup to spray onto surrounding surfaces and dishes; staff reported the part had been missing for several weeks while corporate dietary staff were still in the process of obtaining replacement parts.
Surveyors found that essential kitchen equipment, including a walk-in refrigerator and both ovens, was not maintained in safe operating condition, potentially affecting all 38 residents. The walk-in refrigerator had documented temperatures above safe cold-holding levels over multiple days, with missing temperature entries and no documented food temperature checks or discarding of potentially affected food, despite staff awareness that the unit was in the 50s. The Administrator and Maintenance staff reported delayed notification of the refrigerator problem. Additionally, both kitchen ovens were nonfunctional for an extended period, one having suffered internal fire damage and the other experiencing recurrent failures since purchase, with ongoing electrical and equipment issues despite prior repair attempts.
Surveyors found that kitchen staff did not have access to adequate handwashing facilities while food was being prepared for most residents. One dietary staff member was observed cooking while the front kitchen handwashing sink had no running water, and the back sink lacked soap. The staff member suggested using a pot-filling spigot for handwashing and obtained paper towels from a food preparation area because none were stocked at the front sink. The dietary manager later reported he was unaware the front sink was not working, despite facility policy requiring accessible sinks, soap, and towels.
Failure to Maintain Crash Cart Medications and Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain emergency medications and equipment on the crash cart in safe operating condition. During observation of the crash cart, surveyors identified multiple expired or out-of-date items, including a suction machine with an inspection sticker indicating the next inspection was due several months earlier, five packets of iodine, a bottle of aspirin, a biohazard spill kit, 11 airway tubes, a suction tip, suction tubing, small bore extension kits, a central line dressing kit, and a heat pack, all with past or outdated expiration or use-by dates. The DON, present during the observation, confirmed that the suction machine was past due for inspection and acknowledged the expired supplies, but stated she believed the dates were manufacturing dates rather than expiration dates. The DON reported that the facility conducted monthly checks of the crash cart contents and maintained a binder with a checklist of required equipment. Review of this crash cart binder showed three checklists with all items marked as present, but no expiration dates were documented for any supplies. When a crash cart policy was requested, the office manager confirmed that the facility had no policy regarding the crash cart, its audits, or its maintenance. An undated facility policy titled "Crash Cart Audit Policy and Procedure" stated that crash carts would be maintained in a state of readiness, that missing, expired, or damaged items would be replaced promptly, and that a trained staff member would maintain and routinely monitor a running inventory of expiration dates, but the observations and interviews showed this was not being implemented.
Nonfunctional Phone System on Secured Behavioral Units
Penalty
Summary
The facility failed to maintain a properly operating phone system, resulting in nonfunctional phones on both the Secured Women’s Behavioral Unit and the Secured Men’s Behavioral Unit. On the Secured Women’s Behavioral Unit, surveyor observation with a CNA showed the nurse’s station phone did not work and a second phone on the unit was unplugged and not operational; the CNA confirmed there was no working phone on the unit and stated that if a resident’s family member tried calling in, there was no way to reach staff. On the Secured Men’s Behavioral Unit, observation with another CNA revealed the phone was not plugged in and therefore not operational; this CNA reported the facility had many issues with phones often not working, and the RN assigned to that unit also verified the phone was not operational. The receptionist reported that when she is not on duty, incoming calls roll to the nurse’s station depending on the prompt selected, and acknowledged there had been times recently when the phones were not working. The Administrator stated he did not think it was an issue when families were unable to call into the facility, explained that staff often gave families their personal phone numbers, and confirmed there was no specific policy regarding phones. The deficiency involved all residents on the secured behavioral units, as the lack of functioning phones at the nurse’s stations and within the units meant staff could not be reliably reached through the facility’s phone system, particularly when the receptionist was not present and calls were supposed to roll over to the units.
Failure to Maintain Dishwasher in Working Order
Penalty
Summary
The facility failed to maintain the dishwasher in working order, resulting in prolonged periods when it was non-operational or not functioning correctly. During a kitchen observation with the Dietary Manager, the dishwasher was found to be out of service, and the manager reported ongoing problems since February, including incorrect chemical dispensing during the wash cycle and dishes not coming out clean. The manager stated that technicians had been called frequently and that the machine would work briefly after repairs and then break again. A technician was observed working on the dishwasher during the survey, and the Regional Director of Operations later confirmed that although the dishwasher had worked the previous day, it had again stopped functioning. Because the dishwasher was not operational, the facility used disposable dishware and utensils for all meals, and residents were observed receiving meals in Styrofoam containers with plastic cutlery on multiple days. A resident reported dissatisfaction with the Styrofoam containers, stating that they made it difficult to cut food and that she would cut through the container while trying to eat. Review of the dishwasher temperature log showed the dish machine was documented as broken for multiple extended periods: from 11/21/25 through 11/31/25, 01/24/26 through 02/01/26, 02/07/26 through 03/01/26, and 03/04/26 through 03/17/26. Facility policy on sanitization required all equipment to be maintained in good repair, which was not met during these documented breakdowns.
Failure to Maintain Safe, Functional Kitchen Equipment
Penalty
Summary
The facility failed to ensure essential kitchen equipment was maintained in safe, proper working order, specifically a high-temperature dishwasher and a commercial food processor (Robot Coupe). Surveyors observed the dishwasher operating with a visible leak, with water running out from under and along the side of the machine, down the wall near electrical outlets, and pooling on the floor to a depth of about an inch where staff were standing in wet shoes while operating it. A dish room worker stated it was a pain to stand in the water while keeping dishes moving. The Dietary Supervisor confirmed the dishwasher had been leaking for about three weeks. Maintenance work orders documented a critical-priority leak on one date that was marked completed the same day, and another critical-priority work order the next day stating the leak persisted and was worsening, which was also marked completed later that day. The Maintenance Director reported the concern was first reported when he was off work, that he attempted a repair when he returned, and that the leak continued to worsen. The Dietary Director stated the dishwasher was not actually fixed until a later date, and a plumbing contractor confirmed they were not contacted about repairs until after the surveyors were on site, despite prior failed repairs that had caused leaks. The facility also failed to maintain the Robot Coupe food processor in proper working condition. During observation of pureed food preparation, the food processor was missing the center part of the cover that both sealed the lid and allowed scraping of the sides while the machine was running. The Dietary Supervisor attempted to cover the opening with aluminum foil, but when the machine was turned on, soup sprayed out from under the foil onto the surrounding countertop and onto dishes on a nearby rack. The Dietary Supervisor confirmed the missing part made it more difficult and time-consuming to achieve a smooth puree and that the part had been missing for at least several weeks, with uncertainty about whether it had been ordered. Text messages and emails showed that information for ordering the necessary parts had been sent to corporate dietary staff, that a quote was being obtained, and that the parts were eventually ordered, but the Dietary Manager confirmed the replacement part had not yet been received at the time of the survey. The facility’s policy stated that all foodservice equipment would be clean, sanitary, and in proper working order and routinely maintained per manufacturer directions.
Failure to Maintain Safe, Functional Kitchen Refrigeration and Ovens
Penalty
Summary
The facility failed to maintain essential kitchen electrical equipment, including a walk-in refrigerator and ovens, in safe operating condition. Surveyors observed that the walk-in refrigerator temperature log showed readings above 41°F beginning on 02/04/26, with temperatures documented at 50°F, 56°F, 54°F, and 58°F on various dates, and missing entries on some days. Staff interviews revealed that when a staff member noticed the walk-in felt warmer than the kitchen and reported temperatures in the 50s, the Dietary Manager instructed staff via text to move perishable items to a reach-in refrigerator but did not direct staff to take food temperatures or discard any items. The Dietary Manager stated she deleted the text messages and could not recall who notified her, and she had no paperwork or identification for any service person who allegedly came to check the unit. The Administrator and Maintenance staff both reported that they were not informed of the refrigerator problem until several days after the first elevated temperature was recorded, and they confirmed there was a multi-day delay between the initial temperature issue and their awareness and response. The facility also lacked a functioning kitchen oven system for an extended period. During observation, neither of the two ovens was operational, and it was reported that both became nonfunctioning between 01/30/26 and 02/05/26. One oven, purchased in June 2025, had experienced an internal fire that welded the heating element to the bottom panel, and the other oven, purchased in March 2025, had ongoing operational problems since October 2025, working only intermittently. Maintenance staff described the second oven as a “lemon” and reported that the manufacturer attributed the failures to incorrect electrical wattage supplied by the facility. An invoice showed both ovens were down and had been repaired on 01/30/26, with additional electrical panel troubleshooting on 02/02/26, but by the time of the survey the kitchen still did not have a working oven. These conditions demonstrated that essential electrical kitchen equipment was not maintained in safe and reliable operating condition, with the potential to affect all 38 residents in the facility.
Inadequate Handwashing Facilities in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to ensure kitchen staff had access to adequate, functioning handwashing facilities in the kitchen. Upon entering the kitchen at 8:00 A.M., a surveyor observed a dietary staff member cooking scrambled eggs at the stove. When the surveyor attempted to use the handwashing sink at the front of the kitchen, the water did not flow. The dietary staff member confirmed the sink was not working and directed the surveyor to use the handwashing sink at the back of the kitchen, stating this was where he normally washed his hands. At the back handwashing sink, the surveyor found there was no soap available, which the dietary staff member confirmed, suggesting the surveyor obtain soap from the non-functioning front sink. The dietary staff member then turned on water from a pot-filling spigot that had been pulled over the sink and suggested it could be used for handwashing. There were no paper towels at the front handwashing sink, and the dietary staff member retrieved a roll of paper towels from the food preparation area and handed it to the surveyor. Later, the dietary manager stated he was not aware that the front handwashing sink was not working and verified that hand soap should be available at all kitchen handwashing sinks. The facility census was 78 residents, with 76 receiving food from the kitchen, and the facility’s handwashing policy required that sinks, soap, and towels be readily accessible and convenient for staff use.
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