Failure to Maintain Safe and Functional Equipment
Penalty
Summary
The facility failed to ensure that all mechanical, electrical, and patient care equipment was maintained in safe operating condition. Specifically, the commercial electric dishwasher in the kitchen had a malfunctioning temperature gauge, which had been reading below the manufacturer's required minimum of 120°F for effective sanitization. Dietary staff and the Food Service Manager (FSM) were aware of the issue, and logs showed temperature readings ranging from 100°F to 120°F. Although a handheld thermometer showed the water temperature was sufficient, the built-in gauge had been malfunctioning since April, and there was no documented evidence of a maintenance technician's visit or a work order to address the problem. Additionally, one of two beds in an occupied resident room was found without a mattress for approximately a month following the passing of a hospice resident. Staff interviews revealed uncertainty about why a new mattress had not been placed on the bed, and the Director of Nursing (DON) acknowledged awareness of the risk posed by an exposed metal bed frame. The facility's equipment safety and maintenance policy required prompt reporting and addressing of equipment malfunctions, but these procedures were not effectively followed in these instances.