Ice Machines Not Maintained in Sanitary Condition
Summary
Surveyors found that the facility failed to maintain three ice machines in sanitary working condition, as required by federal regulations. During observations with the Maintenance Director, residues of various colors (brown, yellow, gray, black, and red) were found on critical internal components of the ice machines, including the evaporator, water curtain, ice chute, and ice storage bin deflector. Additionally, stained metal screws were observed in the ice storage bin. These findings were verified by the Maintenance Director during the inspection. Further review revealed that the facility did not follow manufacturer specifications for cleaning one of the ice machines. The manufacturer’s instructions required the use of a specific scale remover (Scotsman Clear 1), but the vendor responsible for cleaning the machines used a generic cleaner (Nucalgon nickel safe ice machine cleaner) instead, citing cost and practicality as reasons. The vendor admitted to not using the appropriate cleaner for each brand of ice machine. At the time of the survey, 145 residents were receiving oral diets and were potentially affected by the condition of the ice machines.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: 145 residents were affected by this deficient practice. On 7/15/25, all three ice machines were immediately taken out of service by the maintenance director and designee; certified vendor inspected, served, and thoroughly sanitized the ice machines following the manufacturer's specific cleaning and scale removal instructions. On 7/16/25, Dietary Supervisor and designee contacted certified vendor to initiate replacement of identified non-compliant ice machines, and vendor confirmed delivery and installation of new ice machines on 8/1/25. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have the potential to be affected by this deficient practice. On 8/1/2025, Administrator and Maintenance Director checked all ice-handling processes and related equipment. All ice machine equipment was cleaned and sanitized. The ice machine inside the kitchen was replaced on 8/1/2025. No other noncompliance was found. On 8/1/2025, Ice machine technician in-serviced maintenance department on how to clean and sanitize the ice machine, making sure deep cleaning was done including compartments not easily visible using approved chemical for cleaning ice machine. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: Administrator or designee will oversee this process and compliance. Maintenance will do monthly deep cleaning and sanitation of ice machine. The dietary supervisor and designee will do daily ice machine cleaning and inspection, with records kept. Vendor will perform quarterly service and cleaning to ensure cleanliness and compliance with equipment and sanitation protocols. Administrator or designee will check the ice machine weekly and randomly for 3 months to make sure cleaning and sanitation compliance is being followed. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance: Integrate QA Process: The Administrator or designee will be responsible for ensuring the monitoring process remains in place to confirm compliance. Any findings and noncompliance will be immediately corrected and presented to the monthly Safety Committee meetings and the Quality Assurance (QA&A) committee meetings. The Plan of Correction was presented at the QA&A meeting on 8/14/25. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for 3 months. 5. Corrective action completion date: 8/1/2025. --- 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Residents 35, 36, 49, 51, 85, 122, 146, and 153 were affected by this deficient practice. On 7/23/2025, Maintenance Director re-assessed all residents 35, 36, 49, 52, 85, 122, 146, and 153 for entrapment to make sure measurement of zone 7 reflected on the form being used. On 7/23/2025, Administrator provided 1:1 in-serviced to Maintenance Director for facility policy and procedure for measuring entrapment and using the form that reflects zone 7 to show if it passes or fails.
Penalty
Resources
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The facility failed to keep a kitchen dishwashing system in good working order when surveyors observed water flowing from a metal device under the counter, with buckled tile and peeled-back wall trim nearby. A kitchen staff member said maintenance had known about the leak for about a month, and maintenance later confirmed the issue had not been reported through the TELS system and that the damage was not new.
Lint Buildup in Dryer Lint Trap: One of two dryers was observed running with lint buildup in the lint trap after the lint door was opened during a laundry tour. The MSS stated the lint trap should be cleaned every 2 hours for fire safety, and an LA stated she forgot to clean Dryer 2's lint trap. Facility policy required laundry equipment to be maintained per manufacturer instructions and kept in a safe, operable condition.
Essential kitchen equipment was not kept in good working condition. A large kitchen refrigerator had standing water on the bottom shelf and water dripping from the top onto covered food, and a resident refrigerator freezer had heavy ice buildup with a splintered gasket that did not attach well. The ADON and Maintenance Director both verified the equipment problems, and the MD stated the refrigerator was not working properly and needed repaired.
Dishwasher Thermometer Inaccurate and Temps Below Required Level: The low-temp dishwasher was observed with wash and rinse temps below the facility's required 120F minimum, and the DS stated staff had to handwash dishes while the machine was out of order. The MS later found the machine's thermometer was not reading accurately, with the manual thermometer showing 135.1F while the machine read 118F, and the DS said the length of time the thermometer had been inaccurate was unknown.
Kitchen equipment was not maintained in safe operating condition. A plate warmer was plugged in but only held room-temperature plates, and staff said it had not warmed plates since the prior week or earlier. A dishwasher temperature gauge was also faulty, reading 110F while a separate gauge showed the water was 122F during operation. The Maintenance Director said he had not been notified of either issue and found no June maintenance entries for the plate warmer or dishwasher gauge.
Kitchen equipment was not maintained in proper working order, affecting nearly all residents who received meals from the kitchen. Surveyors observed significant ice buildup in two reach-in freezers, including on food products, and found the garbage disposal covered. Dietary staff said the disposal had been broken for about a year, and the DM reported the freezers were constantly in defrost with possible door seal problems. Maintenance confirmed the disposal needed replacement and said approval was delayed because the facility was being sold.
Kitchen Dishwashing System Leak Not Maintained
Penalty
Summary
The facility failed to maintain equipment in good working order for one kitchen dishwashing system and the surrounding area. During an initial kitchen tour, surveyors observed dishwater and a metal device underneath the counter with a large amount of water flowing from it, along with a buckled tile floor and peeled-back trim around the perimeter of the wall. A kitchen staff member stated maintenance had known about the water leak for about a month. When maintenance reviewed the area, the water was turned off, and maintenance stated staff are expected to report needed repairs through the TELS system, but the issue had not been reported. Maintenance confirmed the damage was not new and should have been reported sooner, and stated a plumber would be coming to assess the leak. The administrator later confirmed the expectation that staff use the TELS system for items needing repair and stated they had been updated that a plumber had been called.
Lint Buildup in Dryer Lint Trap
Penalty
Summary
Essential laundry equipment was not maintained in safe operating condition when one of two dryers was found operating with lint buildup in the lint trap. During a laundry tour, Laundry Aid 1 opened the lint door underneath Dryer 2 and observed lint buildup on the lint trap while the dryer was running without any items inside. The Maintenance Service Supervisor stated the dryer lint trap should be cleaned every 2 hours for fire safety and prevention, and Laundry Aid 2 stated she forgot to clean the lint trap of Dryer 2 at 2 PM and that the dryer should be regularly cleaned and free from lint buildup. Facility policy for Laundry stated equipment will be used and maintained according to manufacturer instructions, and the Preventative maintenance program policy stated the maintenance director is responsible for maintaining a schedule so buildings, grounds, and equipment are kept in a safe and operable manner.
Kitchen Refrigeration Not Maintained in Working Condition
Penalty
Summary
Essential kitchen equipment was not maintained in good working condition. During an initial kitchen tour and a later observation, the large three-door refrigerator had one quarter to one half inch of standing water on the bottom shelf and water dripping from the top, and bags of food were wet from the dripping water. On the 200 unit, a resident refrigerator freezer had a heavy one half inch build-up of white ice on the top and side surfaces, and the gasket around the freezer was splintered and did not attach well to the compartment. An ADON verified the freezer gasket was in disrepair and did not attach well, and the Maintenance Director verified the kitchen refrigerator had standing water in the bottom, water dripping from inside the top onto covered food, and that the refrigerator was not working properly and needed repaired. The facility policy stated maintenance would attempt repairs and use outside contractors if unable to complete them.
Dishwasher Thermometer Inaccurate and Temperatures Below Required Level
Penalty
Summary
The facility failed to maintain the dishwashing machine in safe operating condition. During observation and interview, the Dietary Supervisor stated the low-temperature dishwasher was required to log wash and rinse temperatures of at least 120 degrees Fahrenheit to properly clean dishware. When the machine was run three times, the recorded temperatures were below that level, with wash temperatures of 110 degrees Fahrenheit on all three runs and rinse temperatures of 110, 110, and 112 degrees Fahrenheit. The Dietary Supervisor stated the machine was not reaching the goal temperature and that staff had to use the two-compartment sinks to handwash dishes while the machine was out of order. During interview and observation, the Maintenance Supervisor manually checked the dishwasher water temperature and found the manual thermometer read 135.1 degrees Fahrenheit while the dishwasher's thermometer read 118 degrees Fahrenheit. The Maintenance Supervisor stated the dishwasher thermometer was not reading accurately. The Dietary Supervisor stated she did not know how long the thermometer had been inaccurate, but the last inspection by the dishwasher company had been on 6/16/26. The facility policy for chemical low-temperature dish machines stated they must maintain a water temperature of 120F to 140F.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition. During an observation and interview, the kitchen's electrical plate warmer was plugged into the outlet but contained room-temperature plates, and the FSM and another staff member stated it had not warmed plates since the prior week or possibly earlier. The FSM said the plate warmer had been entered into the facility's maintenance care program, which was supposed to alert the Maintenance Director to the needed repair. During another observation and interview, the kitchen dishwasher's temperature gauge read 110F during operation and after operation, while the FSM used a separate temperature gauge and demonstrated that the water temperature during operation was 122F. The FSM stated that the safe operating temperature was over 120F and identified the dishwasher gauge as faulty. The Maintenance Director later stated he had not been notified of the faulty kitchen equipment and found no June 2026 maintenance entries for either the plate warmer or the dishwasher gauge in the maintenance care database. A record review of the facility's preventive maintenance policy stated that the facility would maintain a comprehensive preventive maintenance program for essential operating equipment and document all preventive maintenance.
Kitchen Equipment Not Maintained in Working Order
Penalty
Summary
The facility failed to maintain kitchen equipment in proper working order, affecting all 39 residents who received food from the kitchen except one resident who had orders for nothing by mouth. Maintenance records showed dietary staff reported the garbage disposal was not working on 07/21/25, but the work order was not set to completed until 08/29/25. A repair quote dated 03/11/26 showed the garbage disposal needed replacement. During an observation on 06/15/26, surveyors found reach-in freezer #1 and reach-in freezer #2 had significant ice buildup, including on food products, and the garbage disposal had a cover over it. Dietary staff confirmed the ice buildup and stated the garbage disposal had been broken for about a year and the facility did not want to pay to fix it. The Dietary Manager stated the two reach-in freezers were constantly in a state of defrost and believed there was something wrong with the door seals. The Maintenance Director confirmed the garbage disposal needed replacement and stated the quote was not approved until 06/15/26 because the facility was being sold.
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