Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the walk-in freezer in the kitchen, which was observed to have significant ice buildup in several areas. During multiple observations and interviews, ice accumulation was noted on the door frame, an electrical box, a shelving rack, a laminated storage chart, and a thermometer. The registered dietician and certified dietary manager both confirmed the presence of ice buildup, and the issue was documented in monthly audits as not being met. The ice buildup was first noticed by the certified dietary manager in February, and subsequent audits in February and April continued to note the deficiency. Despite the ongoing issue, there was a lack of maintenance logs or documentation regarding troubleshooting efforts by facility staff. The facility engaged a third-party vendor to service the freezer, including replacing a valve cord and compressor, and conducting diagnostics, but there was no written record of the diagnostic findings or recommendations. A second vendor was later consulted, but no repairs were made between vendor visits, and the ice buildup persisted. Parts needed for repair were not ordered until after the state surveyor's inspection, and there was no documentation of discussions or decisions made regarding the delay in repairs. Interviews with the maintenance director revealed that some attempts were made to address the issue, such as replacing the door gasket and latch, but these actions were not documented, and the director could not recall when the work was performed. The infection preventionist's audit only checked the temperature log and did not inspect the freezer for ice buildup. Job descriptions for the culinary director and registered dietician indicated responsibility for maintaining documentation and compliance with food storage requirements, but the ongoing ice buildup and lack of documentation demonstrated a failure to meet these standards.