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F0689
L

Unattended Hot Equipment Creates Accident Hazards for Cognitively Impaired Residents

Centralia, Kansas Survey Completed on 08-12-2025

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 an environment free from accident hazards by leaving an active steam table, which reached temperatures up to 180 degrees Fahrenheit, unattended and accessible in the dining room. At the time, the dining room was empty of both residents and staff, and the steam table was accessible from all sides. The facility had three cognitively impaired, independently mobile residents who could potentially access the steam table without staff knowledge. Dietary staff reported turning on the steam table early in the morning and leaving it on throughout the day without monitoring its temperature. Additionally, the facility did not ensure that residents were protected from another accident hazard involving an unlocked blanket warmer. The blanket warmer was located in an open, unattended room without a door, and was placed on a shelf approximately 2 ½ feet from the floor. The temperature of the blanket warmer was measured at over 150 degrees Fahrenheit, and the metal shelf inside was hot to the touch. Staff confirmed that the blanket warmer was accessible and that the room was not secured, although they stated they had not observed residents entering the room. The facility's own safety policy required that all electrical machines with heat-producing elements be turned off when not in use, and that unsafe conditions be reported to supervisors. Despite this, the steam table was left on and unattended, and the blanket warmer was left accessible in an unsecured area. The facility was unable to provide an accident policy when requested.

Removal Plan

  • A staff member was placed in the dining room to ensure no residents got close to the steam table.
  • The steam tables have been shut off. Once it is cool, staff will not be in the area until the table is turned back on for the evening service meal.
  • A temporary barrier with cones, chairs, and caution tape to keep folks away from the area.
  • A board barrier will then be put up as a more secure yet temporary fix.
  • A long-term plan will be put in place, likely building up the partial wall that was already in place, to shield the steam table.
See complete original report
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