Fatal Incident Due to Improper Mechanical Lift Operation
Summary
The facility failed to effectively inspect and operate a mechanical lift safely during the transfer of a resident, resulting in a fatal incident. Two CNAs, Staff A and Staff B, were involved in transferring the resident from the bed to a chair using the mechanical lift. During the transfer, the lift unexpectedly continued to rise, and when Staff B attempted to stabilize the situation by grabbing the lift pad, the resident fell from the lift and sustained severe head injuries. The resident was subsequently transferred to a hospital, where they expired approximately four hours after the fall. The resident involved had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and unspecified dementia. The resident was dependent on staff for transfers due to impairments in both upper and lower extremities. The care plan for the resident included the use of a mechanical lift for transfers, which was not executed safely during the incident. The facility's policies required that mechanical lifts be inspected before use and that staff be trained and competent in their operation, but these measures were not effectively implemented in this case. Interviews with staff revealed that the mechanical lift involved in the incident was functioning correctly at the time of the surveyor's inspection. However, the incident report suggested that Staff A may have inadvertently pressed the remote control, causing the lift to rise unexpectedly. This prompted Staff B to grab the lift pad, leading to the resident's fall. The facility's maintenance logs indicated that the lifts were inspected regularly, but the training and competency of the staff in using the lifts were called into question following the incident.
Removal Plan
- Lift #846 inspected and found to be functioning correctly, stored in the maintenance room.
- Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B.
- Safe and Proper Handling of Mechanical lifts training/competencies completed for all nurses and CNAs.
- ADHOC Quality Assurance and Performance Improvement meeting on Mechanical lift transfers completed with the QAPI team.
- Safe Handling policy for Mechanical lifts reviewed with DON, ADON, NHA, Unit Managers, attendees documented on the QAPI sign in sheet.
- Medical Equipment Company checked all mechanical lifts to ensure they were functioning properly; no areas of concern reported.
- Maintenance Mechanical lift logs completed by Maintenance Director.
- Residents' Kardex audited/updated for mechanical lift pad sizes.
- Mechanical sling size assessment for the 60 residents using mechanical lifts completed by Unit Managers.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Staff failed to maintain essential kitchen equipment when the condensation pipe carrying condensate wastewater from the air condenser in the walk-in freezer was found leaking during a kitchen tour. The issue was confirmed in an interview with the kitchen manager and the corporate chef, who acknowledged the ongoing leak in the freezer’s condensation piping.
The facility failed to maintain its ice machine in safe operating condition, resulting in no ice being available to residents for two days. Two cognitively intact residents, one with an indwelling catheter, neuromuscular bladder dysfunction, pressure ulcer, protein-calorie malnutrition, and paraplegia, and another with cerebral palsy, breast cancer, bipolar disorder, and a recent UTI, reported they had no ice and drank less because they preferred ice-cold fluids. CNAs, an LVN, dietary staff, and the Director of Maintenance confirmed the ice machine’s dispenser repeatedly came off track, that no ice was available on the units or in kitchen freezers, and that the usual process of stocking ice chests at the nurses’ station was not followed. The MDS coordinator, DON, administrator, and other department heads either were not notified in a timely manner or did not follow up after receiving notice, despite facility policy and manufacturer guidelines requiring proper maintenance and operation of the ice machine to assure a safe supply of ice.
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 failed to keep essential kitchen equipment in safe operating condition, leading to hot foods being served at improper temperatures. During lunch service, kitchen staff continued preparing trays after the last cart had left, and a test tray later showed ham, sweet potatoes, and collard greens all below appropriate hot-holding temperatures. A Certified Dietary Manager acknowledged the temperatures were not proper and reported that the plate warmer functioned correctly only briefly and that the pellet warmer, though initially reaching 135°F, cooled too quickly when taken out for use.
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 the facility did not maintain required documentation showing that an outside contractor was performing scheduled preventive maintenance on the HVAC system. The Maintenance Supervisor reported having no logs or reports of semi-annual HVAC service visits and acknowledged that such records should have been kept to monitor compliance and system function. The Administrator also confirmed that copies of HVAC maintenance records were not on file, despite facility policy assigning the maintenance director responsibility for maintaining maintenance schedules and related reports in the maintenance office.
Failure to Maintain Walk-In Freezer Condensation System
Penalty
Summary
Facility staff failed to maintain essential kitchen equipment, specifically the walk-in freezer, in good working order. During the initial kitchen tour on 03/24/2026 at approximately 10:15 AM, surveyors observed that the condensation pipe conveying condensate wastewater from the air condenser in the walk-in freezer was leaking. In a face-to-face interview conducted shortly thereafter on 03/24/2026 at approximately 10:30 AM, the Kitchen Manager (Employee #6) and the Corporate Chef (Employee #7) acknowledged the observed leak from the condensation pipe in the walk-in freezer.
Failure to Maintain Ice Machine and Provide Ice for Residents
Penalty
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.
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 Kitchen Equipment Resulting in Improper Hot Food Temperatures
Penalty
Summary
The facility failed to maintain essential kitchen equipment in proper operating condition, resulting in hot foods not being held at appropriate temperatures during lunch service. On 03/11/26 at 11:43 a.m., the surveyor observed kitchen staff preparing lunch trays, with the last cart leaving the kitchen at 12:25 p.m., after which staff continued to prepare additional lunch trays that could not be placed in the cart due to lack of space. A test tray was prepared for the surveyor, and at 1:00 p.m. the surveyor measured the temperatures of the foods on a regular tray, finding the ham at 118.8°F, sweet potatoes at 121.3°F, and collard greens at 120.9°F, all below proper hot-holding temperatures. During an interview on 03/17/26 at 10:51 a.m., the Certified Dietary Manager acknowledged that none of the recorded temperatures were proper and reported that an electrician had been called to repair the plate warmer and pellet warmer; the plate warmer only worked properly for about an hour, and the pellet warmer initially read 135°F but cooled too quickly when pulled out for use.
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.
Lack of Documentation for HVAC Preventive Maintenance by Outside Contractor
Penalty
Summary
The deficiency involves the facility’s failure to maintain documented evidence that its Heating, Ventilation, and Air Conditioning (HVAC) system was being serviced and maintained by an outside HVAC contractor to ensure it was safe and in good working condition. Review of the undated floor plan showed 54 resident rooms across two floors, and a census report showed 95 residents in the facility with a bed capacity of 99. During interviews and record review, the Maintenance Supervisor was unable to provide any logs, records, or reports of semi-annual HVAC maintenance visits by the outside company since he had been employed in the role. He acknowledged that he did not have a log or record of maintenance visits and that he should have been tracking HVAC maintenance by outside companies to monitor compliance and ensure the system remained safe and functional. Further interviews with the Administrator confirmed that the facility did not have copies of HVAC maintenance visit records on hand to verify that the system was being checked and maintained to keep temperatures within normal ranges. The Administrator stated that documentation of maintenance services from outside companies should be available to ensure the HVAC system was being checked, safe, and working properly, and noted that a request for past service records had only been sent on the day of the survey. Review of the facility’s “Maintenance Service” policy and procedure, dated 2001, indicated that the maintenance director (maintenance supervisor) is responsible for maintaining records and reports of work order requests and maintenance schedules, and that these records are to be maintained in the maintenance director’s office. Despite this policy, the required HVAC maintenance documentation was not available during the survey.
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