Improper Installation and Maintenance of PACUs
Summary
The facility failed to ensure the proper installation and maintenance of portable air conditioning units (PACUs) in 12 rooms. Observations revealed that the exhaust hoses of the PACUs were duct taped to window frames, rendering the windows inoperable. The slider kits provided with the PACUs were too short for the facility's window size, leading to the use of cardboard to fill gaps and duct tape to secure the installation. This improper installation could prevent windows from being opened in emergencies, such as a fire. Additionally, the facility did not adhere to the manufacturer's guidelines for cleaning the air filters of the PACUs. The Maintenance Supervisor (MS) admitted to cleaning the air filters every three months, contrary to the manufacturer's instructions, which required cleaning every two weeks. The MS was unaware that each PACU had two filters and lacked documentation or a tracking method for filter maintenance. This oversight could lead to poor air quality due to dust accumulation, affecting the performance of the air conditioning units.
Penalty
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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.
The facility did not maintain its boiler in working condition, resulting in low temperatures throughout common areas such as hallways, dining rooms, and lounges. Residents were observed bundled in coats and blankets, and auxiliary heaters were used but were often ineffective. While PTAC units were installed in resident rooms, common areas remained inadequately heated, and staff confirmed ongoing temperature issues and equipment malfunctions.
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.
Failure to Maintain Safe and Functional Heating in Common Areas
Penalty
Summary
The facility failed to maintain essential mechanical equipment, specifically the boiler, in a functional and safe operating condition, which resulted in inadequate heating throughout multiple common areas and resident-accessible spaces. Observations revealed that temperatures in the main entrance, administration offices, dining room, hallways, chapel, and common gathering rooms were significantly below the facility's policy requirement of 71-81 degrees Fahrenheit, with recorded temperatures ranging from 48.5 to 61.6 degrees Fahrenheit. Residents were observed wearing winter coats, sweatshirts, hats, and blankets to keep warm while ambulating or self-propelling in these areas. The boiler was found to be permanently shut off with exposed wires, and auxiliary heaters were being used as supplemental heat sources, some of which were not functioning properly. Interviews with the Maintenance Director and Administrator confirmed the non-functional status of the boiler and the ongoing low temperatures in the affected areas. The facility had installed PTAC units in resident rooms, allowing residents to control their room temperatures, but did not address heating in the common areas linked to the non-functional boiler. Discrepancies were noted between actual room temperatures and those displayed on PTAC units, with some units requiring frequent resets. The dining room had been closed for at least two years due to the lack of heat, and the Administrator stated that heating common areas was not a priority as they believed it did not affect resident care.
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