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F0908
D

Failure to Maintain Safe and Operable Equipment

San Rafael, California Survey Completed on 08-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain essential equipment in a safe and operable condition, as evidenced by two specific deficiencies. In the laundry room, one of the laundry machines was observed to be broken and covered in rust. The Maintenance Director (MDR) confirmed the machine was not functioning and acknowledged that maintenance was only performed when equipment was already malfunctioning, rather than on a regular schedule. The Housekeeping Staff stated that the broken machine had been out of service for an extended period, causing delays in the laundry process for residents. Additionally, the MDR was unable to locate the laundry machine manual, which was noted as important for troubleshooting. In a resident's room, Certified Nursing Assistants (CNAs) were unable to lock the bed due to malfunctioning bed locks. The MDR and the Director of Nursing (DON) both confirmed that the bed locks were not working and emphasized the importance of functioning bed locks to prevent falls and injuries. The resident involved had a history of left hip prosthesis dislocation, Huntington's disease, and a previous fall from a chair. Review of the facility's maintenance policy indicated that the maintenance department was responsible for ensuring all equipment was kept in a safe and operable manner at all times, including providing regularly scheduled maintenance.

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